Provider Demographics
NPI:1487495925
Name:HAVEN FAMILY DENTAL
Entity type:Organization
Organization Name:HAVEN FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEYROLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTTROS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-238-7959
Mailing Address - Street 1:2722 CATON FARM RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-1309
Mailing Address - Country:US
Mailing Address - Phone:815-782-6409
Mailing Address - Fax:
Practice Address - Street 1:2722 CATON FARM RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1309
Practice Address - Country:US
Practice Address - Phone:402-238-7955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-06
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty