Provider Demographics
NPI:1477122786
Name:OTTO, ANDREW (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:OTTO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 SHAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-1804
Mailing Address - Country:US
Mailing Address - Phone:913-682-2595
Mailing Address - Fax:
Practice Address - Street 1:726 SHAWNEE ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-1804
Practice Address - Country:US
Practice Address - Phone:816-808-1795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS618821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice