Provider Demographics
NPI:1255228755
Name:BOTHRA, PALAK
Entity type:Individual
Prefix:
First Name:PALAK
Middle Name:
Last Name:BOTHRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 COLUMBIA RD APT 1G
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-4014
Mailing Address - Country:US
Mailing Address - Phone:952-855-2188
Mailing Address - Fax:
Practice Address - Street 1:635 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-3550
Practice Address - Country:US
Practice Address - Phone:952-855-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL100422390200000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program