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General NPI Number Information
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NPI Number | 1962940874
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Entity Type | Organization
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Legal Business Name | MATTA BOTROUS DDS INC
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Dates
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Enumeration Date | 02/10/2017
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Last Update Date | 02/10/2017
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Provider Practice Location Address
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Address Line | 10590 TOWN CENTER DR SUITE # 180
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-0360
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Country | US
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Telephone | 714-650-1661
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Fax |
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Provider Business Mailing Address
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Address Line | 10590 TOWN CENTER DR SUITE # 180
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-0360
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Country | US
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Telephone | 714-650-1661
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MATTA JOSEPH MATTA BOTROUS
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Credential | DDS
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Telephone | 714-650-1661
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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 | 62073
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License Number State | CA
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