Provider Demographics
NPI:1164979464
Name:OTTERSON, SCOTT WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:WILLIAM
Last Name:OTTERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6479 W CARRICK WAY
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-5526
Mailing Address - Country:US
Mailing Address - Phone:610-202-5735
Mailing Address - Fax:
Practice Address - Street 1:146 CLARK RD, BLDG 339
Practice Address - Street 2:USA DENTAL HEALTH ACTIVITY
Practice Address - City:FT SHAFTER
Practice Address - State:HI
Practice Address - Zip Code:96858
Practice Address - Country:US
Practice Address - Phone:808-438-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-02
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12667815-89031223E0200X
IDD-5561-EN1223E0200X
UT12667815-99221223E0200X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics