Provider Demographics
NPI:1619193919
Name:DOHM, OTTO WILLIAM (DDS,MS)
Entity type:Individual
Prefix:
First Name:OTTO
Middle Name:WILLIAM
Last Name:DOHM
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1142 W CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1306
Mailing Address - Country:US
Mailing Address - Phone:702-222-8760
Mailing Address - Fax:701-222-3162
Practice Address - Street 1:1142 W CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1306
Practice Address - Country:US
Practice Address - Phone:702-222-8760
Practice Address - Fax:701-222-3162
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17661223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND901766OtherDSC IDENTIFIER
ND41031Medicaid
ND41031Medicaid