Provider Demographics
NPI:1538586136
Name:PAMELA OTTESEN DMD LLC
Entity type:Organization
Organization Name:PAMELA OTTESEN DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTESEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-582-1009
Mailing Address - Street 1:2030 KILDARE CIR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-7308
Mailing Address - Country:US
Mailing Address - Phone:850-582-1009
Mailing Address - Fax:
Practice Address - Street 1:1536 JOHN SIMS PKWY
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578
Practice Address - Country:US
Practice Address - Phone:850-582-1009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-21
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty