Provider Demographics
NPI:1467936120
Name:OTTOSON, BEN
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:OTTOSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36000 SHOEMAKER LANE
Mailing Address - Street 2:SUITE 1051
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36000 SHOEMAKER LANE
Practice Address - Street 2:SUITE 1051
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-286-7402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025584122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No122300000XDental ProvidersDentist