Provider Demographics
NPI:1770684466
Name:OTT, COLIN J (DDS)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:J
Last Name:OTT
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 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 STEWART AVE
Practice Address - Street 2:STE 266
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401
Practice Address - Country:US
Practice Address - Phone:715-845-8841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001643204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33558000Medicaid
WI33558000Medicaid