Provider Demographics
NPI:1386651685
Name:OTTO, JANE ALLISON (MAMS, DMD)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:ALLISON
Last Name:OTTO
Suffix:
Gender:F
Credentials:MAMS, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11624 GRAVOIS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-3014
Mailing Address - Country:US
Mailing Address - Phone:314-842-2442
Mailing Address - Fax:314-842-2467
Practice Address - Street 1:11624 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-3014
Practice Address - Country:US
Practice Address - Phone:314-842-2442
Practice Address - Fax:314-842-2467
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0160091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice