Provider Demographics
NPI:1013128867
Name:OTTLEY, ANISSA R (DMD)
Entity type:Individual
Prefix:DR
First Name:ANISSA
Middle Name:R
Last Name:OTTLEY
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 1:4272 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-2808
Mailing Address - Country:US
Mailing Address - Phone:850-626-6100
Mailing Address - Fax:850-626-6100
Practice Address - Street 1:4272 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-2808
Practice Address - Country:US
Practice Address - Phone:850-626-6100
Practice Address - Fax:850-626-6100
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN154811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice