Provider Demographics
NPI:1730072968
Name:OTIS, YVONNE (DMD)
Entity type:Individual
Prefix:
First Name:YVONNE
Middle Name:
Last Name:OTIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:YVONNE
Other - Middle Name:JAQUELINE
Other - Last Name:OTIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:YVONNE OTIS DMD
Mailing Address - Street 1:1025 SE 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2486
Mailing Address - Country:US
Mailing Address - Phone:802-595-1758
Mailing Address - Fax:
Practice Address - Street 1:10300 SE WASHINGTON ST STE C101
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2805
Practice Address - Country:US
Practice Address - Phone:037-763-0915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-28
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD122031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice