Provider Demographics
NPI:1902930159
Name:OTTEN, JOHN J (MD, DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:OTTEN
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4014 LEAVENWORTH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1053
Practice Address - Country:US
Practice Address - Phone:402-559-5999
Practice Address - Fax:402-559-3499
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0237001223G0001X
IL021-0017731223S0112X
NE303171223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL909830OtherMEDICARE PT10
ILL50918Medicare ID - Type Unspecified
ILF60799Medicare UPIN