Provider Demographics
NPI:1992256341
Name:OTTER DENTAL
Entity type:Organization
Organization Name:OTTER DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERICH
Authorized Official - Middle Name:CHRISTOFFER
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-452-7007
Mailing Address - Street 1:1919 LATHROP ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5937
Mailing Address - Country:US
Mailing Address - Phone:907-452-7007
Mailing Address - Fax:
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE 211
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-452-7007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1348122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty