Provider Demographics
NPI:1265111900
Name:BOTERO-GIRALDO, JUAN
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:
Last Name:BOTERO-GIRALDO
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 1:6115 GRANTON AVE APT 6L
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-3326
Mailing Address - Country:US
Mailing Address - Phone:551-497-0859
Mailing Address - Fax:
Practice Address - Street 1:3400 MONTGOMERY HWY STE 1
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1270
Practice Address - Country:US
Practice Address - Phone:334-803-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ALD.007543-C1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program