Provider Demographics
NPI:1306886122
Name:OTTESON, KEVIN H (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:H
Last Name:OTTESON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W ELLIOT RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-1885
Mailing Address - Country:US
Mailing Address - Phone:480-899-6229
Mailing Address - Fax:480-786-5445
Practice Address - Street 1:801 W ELLIOT RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-1885
Practice Address - Country:US
Practice Address - Phone:480-899-6229
Practice Address - Fax:480-786-5445
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ596389OtherPROVIDER ID