Provider Demographics
NPI:1962940874
Name:MATTA BOTROUS DDS INC
Entity type:Organization
Organization Name:MATTA BOTROUS DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTA
Authorized Official - Middle Name:JOSEPH MATTA
Authorized Official - Last Name:BOTROUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-650-1661
Mailing Address - Street 1:10590 TOWN CENTER DR
Mailing Address - Street 2:SUITE # 180
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0360
Mailing Address - Country:US
Mailing Address - Phone:714-650-1661
Mailing Address - Fax:
Practice Address - Street 1:10590 TOWN CENTER DR
Practice Address - Street 2:SUITE # 180
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0360
Practice Address - Country:US
Practice Address - Phone:714-650-1661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62073122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty