Provider Demographics
NPI:1881280568
Name:EXUM, OTERIA MICHELLE (RDH)
Entity type:Individual
Prefix:
First Name:OTERIA
Middle Name:MICHELLE
Last Name:EXUM
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 TIMUQUANA DR
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-6010
Mailing Address - Country:US
Mailing Address - Phone:321-480-0638
Mailing Address - Fax:321-269-6045
Practice Address - Street 1:3245 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3004
Practice Address - Country:US
Practice Address - Phone:321-269-2700
Practice Address - Fax:321-269-6045
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0011991124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist