Provider Demographics
NPI:1427031947
Name:SLATER, OTTO W (DDS)
Entity Type:Individual
Prefix:DR
First Name:OTTO
Middle Name:W
Last Name:SLATER
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 1:205 SOUTHDOWNE DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-3747
Mailing Address - Country:US
Mailing Address - Phone:865-381-8867
Mailing Address - Fax:
Practice Address - Street 1:205 SOUTHDOWNE DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-3747
Practice Address - Country:US
Practice Address - Phone:865-381-8867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN77221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU82687Medicare UPIN
TN3226731Medicare ID - Type Unspecified