Provider Demographics
NPI:1467947879
Name:OTTEN, DYLAN
Entity Type:Individual
Prefix:MR
First Name:DYLAN
Middle Name:
Last Name:OTTEN
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 1:9 GOVERNORS LN
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-1991
Mailing Address - Country:US
Mailing Address - Phone:530-894-6913
Mailing Address - Fax:530-894-6915
Practice Address - Street 1:9 GOVERNORS LN
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1991
Practice Address - Country:US
Practice Address - Phone:530-894-6913
Practice Address - Fax:530-894-6915
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52965225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter