Provider Demographics
NPI:1215541297
Name:BOTROS, DINA
Entity type:Individual
Prefix:DR
First Name:DINA
Middle Name:
Last Name:BOTROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 DIAMANTE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1904
Mailing Address - Country:US
Mailing Address - Phone:714-388-2835
Mailing Address - Fax:
Practice Address - Street 1:12025 SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-4922
Practice Address - Country:US
Practice Address - Phone:310-476-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55266183500000X
CA75962183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist