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Individual

LARRY D OTTE

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
D.M.D.

Taxonomy

Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
019-024407
IL
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
021-001850
IL

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
909830
MEDICARE PT10
IL
Enumeration date
03/16/2007
Last updated
10/02/2008
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