Provider Demographics
NPI:1659419273
Name:OTTEN, JUSTIN EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:EDWARD
Last Name:OTTEN
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 1:2255 LEE ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-1670
Mailing Address - Country:US
Mailing Address - Phone:616-532-0501
Mailing Address - Fax:616-532-0501
Practice Address - Street 1:2255 LEE ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-1670
Practice Address - Country:US
Practice Address - Phone:616-532-0501
Practice Address - Fax:616-532-0501
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010125431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice