Provider Demographics
NPI:1275547846
Name:OTTO, PAUL EDWIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:EDWIN
Last Name:OTTO
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 1:233 SOUTHBOUND GRATIOT
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2413
Mailing Address - Country:US
Mailing Address - Phone:586-465-6503
Mailing Address - Fax:586-465-6504
Practice Address - Street 1:233 SOUTHBOUND GRATIOT
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2413
Practice Address - Country:US
Practice Address - Phone:586-465-6503
Practice Address - Fax:586-465-6504
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010105231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice