Provider Demographics
NPI:1225234263
Name:OTTERBECK, PHILIP EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:EDWARD
Last Name:OTTERBECK
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 1:4787 HYLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312
Mailing Address - Country:US
Mailing Address - Phone:718-605-7086
Mailing Address - Fax:718-605-7088
Practice Address - Street 1:4787 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312
Practice Address - Country:US
Practice Address - Phone:718-605-7086
Practice Address - Fax:718-605-7088
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY35259122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist