Provider Demographics
NPI:1588486575
Name:OTTER KIDS PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:OTTER KIDS PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:OTTERSTEDT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-867-5500
Mailing Address - Street 1:1294 OAKMONT DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3762
Mailing Address - Country:US
Mailing Address - Phone:719-867-0550
Mailing Address - Fax:719-867-3191
Practice Address - Street 1:1155 KELLY JOHNSON BLVD
Practice Address - Street 2:STE 210
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920
Practice Address - Country:US
Practice Address - Phone:719-867-0550
Practice Address - Fax:719-867-3191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty