Provider Demographics
NPI:1952441453
Name:OTTESEN, PAMELA ALICIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:ALICIA
Last Name:OTTESEN
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 1:1536 JOHN SIMS PKWY E
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2138
Mailing Address - Country:US
Mailing Address - Phone:850-279-6657
Mailing Address - Fax:850-279-6638
Practice Address - Street 1:1536 JOHN SIMS PKWY E
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2138
Practice Address - Country:US
Practice Address - Phone:315-723-3972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051821-11223G0001X
NY051821122300000X, 1223G0001X
FLDN152111223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist