Provider Demographics
NPI:1437244480
Name:OTTO AND KOTECKI FAMILY DENTISTRY PLC
Entity Type:Organization
Organization Name:OTTO AND KOTECKI FAMILY DENTISTRY PLC
Other - Org Name:WEBER AND OTTO FAMILY DENTISTRY PLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JERALYN
Authorized Official - Middle Name:G
Authorized Official - Last Name:HUISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-424-6461
Mailing Address - Street 1:3223 4TH ST SW
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-1583
Mailing Address - Country:US
Mailing Address - Phone:641-424-6461
Mailing Address - Fax:641-424-9186
Practice Address - Street 1:3223 4TH ST SW
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-1583
Practice Address - Country:US
Practice Address - Phone:641-424-6461
Practice Address - Fax:641-424-9186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0212191Medicaid