Provider Demographics
NPI:1710064910
Name:OTTO, JOSEPH BALZER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:BALZER
Last Name:OTTO
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 1:400 FAIRVIEW SUITE 1
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1910
Mailing Address - Country:US
Mailing Address - Phone:580-765-6633
Mailing Address - Fax:580-765-0803
Practice Address - Street 1:400 FAIRVIEW SUITE 1
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1910
Practice Address - Country:US
Practice Address - Phone:580-765-6633
Practice Address - Fax:580-765-0803
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4550122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist