Provider Demographics
NPI:1508316910
Name:DRS. OTTOSEN AND NYGARD, PLLC
Entity Type:Organization
Organization Name:DRS. OTTOSEN AND NYGARD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:OTTOSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:509-664-6669
Mailing Address - Street 1:1001 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-2604
Mailing Address - Country:US
Mailing Address - Phone:509-766-8968
Mailing Address - Fax:509-766-8967
Practice Address - Street 1:1001 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2604
Practice Address - Country:US
Practice Address - Phone:509-766-8968
Practice Address - Fax:509-766-8967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA604-034-843261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental