MEDICARE: DR. JASON BRYCE BOTTS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	3586	AR
2	1223G0001X	General Practice Dentistry	DS0000008754	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356417687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON BRYCE BOTTS DDS

Provider Business Mailing Address
First Line	:	1055 N HOUSTON LEVEE RD
Second Line	:	SUITE 102
City	:	CORDOVA
State	:	TN
Zip	:	38018-6693
Country	:	US
Telephone Number	:	901-737-2200
Fax Number	:	901-737-2277

Provider Business Practice Location Address
First Line	:	1055 N HOUSTON LEVEE RD
Second Line	:	SUITE 102
City	:	CORDOVA
State	:	TN
Zip	:	38018-6693
Country	:	US
Telephone Number	:	901-737-2200
Fax Number	:	901-737-2277

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	04/23/2009

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