Individual
LARRY D OTTE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.M.D.
Contact information
Practice address
2807 N KNOXVILLE AVE, PEORIA, IL 61604-2869
(309) 682-1213
Mailing address
2807 N KNOXVILLE AVE, PEORIA, IL 61604-2869
(309) 682-1213
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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