Provider Demographics
NPI:1144209032
Name:OTRHALEK, JOHN MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MATTHEW
Last Name:OTRHALEK
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 1:60 COLONIAL RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1775
Mailing Address - Country:US
Mailing Address - Phone:313-886-1739
Mailing Address - Fax:313-884-0777
Practice Address - Street 1:20630 VERNIER RD
Practice Address - Street 2:
Practice Address - City:HARPER WOODS
Practice Address - State:MI
Practice Address - Zip Code:48225-1488
Practice Address - Country:US
Practice Address - Phone:313-884-0040
Practice Address - Fax:313-884-0777
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010119231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice