Provider Demographics
NPI:1386967800
Name:BOETTCHER, JILLIAN C (DDS)
Entity type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:C
Last Name:BOETTCHER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9454 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 311
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212
Mailing Address - Country:US
Mailing Address - Phone:310-550-4525
Mailing Address - Fax:310-820-2916
Practice Address - Street 1:9454 WILSHIRE BLVD
Practice Address - Street 2:SUITE 311
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212
Practice Address - Country:US
Practice Address - Phone:310-550-4525
Practice Address - Fax:310-820-2916
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58918122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist