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General NPI Number Information
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NPI Number | 1356417687
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Entity Type | Individual
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Provider Name | JASON BRYCE BOTTS DDS
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Gender | Male
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 04/23/2009
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Provider Practice Location Address
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Address Line | 1055 N HOUSTON LEVEE RD SUITE 102
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City | CORDOVA
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State | TN
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Zip | 38018-6693
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Country | US
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Telephone | 901-737-2200
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Fax | 901-737-2277
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Provider Business Mailing Address
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Address Line | 1055 N HOUSTON LEVEE RD SUITE 102
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City | CORDOVA
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State | TN
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Zip | 38018-6693
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Country | US
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Telephone | 901-737-2200
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Fax | 901-737-2277
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3586
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DS0000008754
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License Number State | TN
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