Provider Demographics
NPI:1477537637
Name:OTOPALIK, DOUGLAS WADE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WADE
Last Name:OTOPALIK
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 1:127 RED OAK DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-8996
Mailing Address - Country:US
Mailing Address - Phone:507-317-2291
Mailing Address - Fax:
Practice Address - Street 1:111 STAR ST
Practice Address - Street 2:SUITE 109
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4888
Practice Address - Country:US
Practice Address - Phone:507-387-3249
Practice Address - Fax:507-387-7175
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN299220500OtherMEDICAL ASSISTANCE PROV #