Provider Demographics
NPI:1144679903
Name:BOTTORFF, NICHOLAS
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:BOTTORFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13817 FOGGY HILLS CT
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:VA
Mailing Address - Zip Code:20124-2409
Mailing Address - Country:US
Mailing Address - Phone:703-981-5829
Mailing Address - Fax:
Practice Address - Street 1:240 HYDRAULIC RIDGE RD STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-8130
Practice Address - Country:US
Practice Address - Phone:434-979-1365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-12
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014152431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice