Provider Demographics
NPI:1295809879
Name:OTTO, ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:OTTO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 W. JEFFERSON ST.
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-9002
Mailing Address - Country:US
Mailing Address - Phone:630-554-9100
Mailing Address - Fax:630-554-1809
Practice Address - Street 1:21 W. JEFFERSON ST.
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-9002
Practice Address - Country:US
Practice Address - Phone:630-554-9100
Practice Address - Fax:630-554-1809
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice