Provider Demographics
NPI:1659894343
Name:OTIS, BRYAN J (DDS)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:OTIS
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 1:4957 SWINYAR DR
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-2204
Mailing Address - Country:US
Mailing Address - Phone:423-396-3154
Mailing Address - Fax:
Practice Address - Street 1:4957 SWINYAR DR
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-2204
Practice Address - Country:US
Practice Address - Phone:423-396-3154
Practice Address - Fax:423-396-3154
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN105971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice