Provider Demographics
NPI:1063632818
Name:OTTE, RAYMOND C (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:C
Last Name:OTTE
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 1:112 W. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:GOREVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62939-0008
Mailing Address - Country:US
Mailing Address - Phone:618-995-9777
Mailing Address - Fax:
Practice Address - Street 1:112 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:GOREVILLE
Practice Address - State:IL
Practice Address - Zip Code:62939-0008
Practice Address - Country:US
Practice Address - Phone:618-995-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0176541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice