Provider Demographics
NPI:1316004310
Name:ORTMAN, TERRY JON (DDS)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:JON
Last Name:ORTMAN
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 1:2802 BRYDEN LN
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-4709
Mailing Address - Country:US
Mailing Address - Phone:618-467-2878
Mailing Address - Fax:
Practice Address - Street 1:4119 HUMBERT RD
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-7116
Practice Address - Country:US
Practice Address - Phone:618-465-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice