Provider Demographics
NPI:1275646820
Name:OTT, ANGELA BURLESON (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:BURLESON
Last Name:OTT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4030 SMITH RD STE 110
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-1937
Mailing Address - Country:US
Mailing Address - Phone:513-631-8920
Mailing Address - Fax:513-616-4981
Practice Address - Street 1:4030 SMITH RD STE 110
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209-1937
Practice Address - Country:US
Practice Address - Phone:513-631-8920
Practice Address - Fax:513-631-8921
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-022399122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist