Provider Demographics
NPI:1215981352
Name:BOBOTIS, HARRY NICK (DMD)
Entity type:Individual
Prefix:DR
First Name:HARRY
Middle Name:NICK
Last Name:BOBOTIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 VILSECK ROAD
Mailing Address - Street 2:BLDG 419-2
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31315
Mailing Address - Country:US
Mailing Address - Phone:912-257-7056
Mailing Address - Fax:912-257-7055
Practice Address - Street 1:112 VILSECK ROAD
Practice Address - Street 2:BLDG 419-2
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31315
Practice Address - Country:US
Practice Address - Phone:912-257-7056
Practice Address - Fax:912-257-7055
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34901223G0001X
GADN011989122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ34909Medicaid