Provider Demographics
NPI:1457399271
Name:OTTERHOLT, DANA ERIC (DDS)
Entity type:Individual
Prefix:DR
First Name:DANA
Middle Name:ERIC
Last Name:OTTERHOLT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-9452
Mailing Address - Country:US
Mailing Address - Phone:360-424-8804
Mailing Address - Fax:
Practice Address - Street 1:104 N 15TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-3405
Practice Address - Country:US
Practice Address - Phone:360-424-9045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA49621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice