Provider Demographics
NPI:1023418902
Name:OTT, AMY GRACE (DDS)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:GRACE
Last Name:OTT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-1071
Mailing Address - Country:US
Mailing Address - Phone:715-268-7177
Mailing Address - Fax:
Practice Address - Street 1:404 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1071
Practice Address - Country:US
Practice Address - Phone:715-268-7177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1000996-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice