Provider Demographics
NPI:1194859355
Name:OTTE, LARRY D (DMD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:OTTE
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 1:2807 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2869
Mailing Address - Country:US
Mailing Address - Phone:309-682-1213
Mailing Address - Fax:
Practice Address - Street 1:2807 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-2869
Practice Address - Country:US
Practice Address - Phone:309-682-1213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0244071223G0001X
IL021-0018501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL909830OtherMEDICARE PT10
IL909830OtherMEDICARE PT10
ILU67952Medicare UPIN