Provider Demographics
NPI:1225476880
Name:OTTO, KRISTAN NICOLE (RDA)
Entity Type:Individual
Prefix:
First Name:KRISTAN
Middle Name:NICOLE
Last Name:OTTO
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12121 WILSHIRE BLVD
Mailing Address - Street 2:1111
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1123
Mailing Address - Country:US
Mailing Address - Phone:310-820-9933
Mailing Address - Fax:310-820-0408
Practice Address - Street 1:12121 WILSHIRE BLVD
Practice Address - Street 2:1111
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1123
Practice Address - Country:US
Practice Address - Phone:310-820-9933
Practice Address - Fax:310-820-0408
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD160110472126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant