Provider Demographics
NPI:1821003682
Name:OTTALLAH, EMAN K (DMD)
Entity Type:Individual
Prefix:
First Name:EMAN
Middle Name:K
Last Name:OTTALLAH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N STAR AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-7615
Mailing Address - Country:US
Mailing Address - Phone:850-871-6246
Mailing Address - Fax:
Practice Address - Street 1:200 N STAR AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-7615
Practice Address - Country:US
Practice Address - Phone:850-871-6246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17558122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist