Provider Demographics
NPI:1477532968
Name:OTTE, KEVIN JACK (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JACK
Last Name:OTTE
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:NHCGL 3001A SIXTH STREET
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-0000
Mailing Address - Country:US
Mailing Address - Phone:847-688-5568
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HEALTH CLINIC GREAT LAKES
Practice Address - Street 2:DENTAL DIRECTORATE
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60088
Practice Address - Country:US
Practice Address - Phone:847-688-5547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190232771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice