Provider Demographics
NPI:1003971847
Name:MARES, OTTO F (DDS)
Entity type:Individual
Prefix:DR
First Name:OTTO
Middle Name:F
Last Name:MARES
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 1:502 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-1904
Mailing Address - Country:US
Mailing Address - Phone:618-542-3032
Mailing Address - Fax:314-667-5670
Practice Address - Street 1:502 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1904
Practice Address - Country:US
Practice Address - Phone:618-542-3032
Practice Address - Fax:314-667-5670
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice