Provider Demographics
NPI:1699821181
Name:OTTERSTEDT, KENNETH J (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:OTTERSTEDT
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 1:1294 OAKMONT DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3762
Mailing Address - Country:US
Mailing Address - Phone:858-692-1661
Mailing Address - Fax:
Practice Address - Street 1:9480 BRIAR VILLAGE PT
Practice Address - Street 2:SUITE 301
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7922
Practice Address - Country:US
Practice Address - Phone:719-522-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002022901223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry