Provider Demographics
NPI:1932800497
Name:OTTO, JULIE (RDH AOMT-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:RDH AOMT-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 OBERLIN RD
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-7621
Mailing Address - Country:US
Mailing Address - Phone:989-302-0055
Mailing Address - Fax:
Practice Address - Street 1:811 OBERLIN RD
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-7621
Practice Address - Country:US
Practice Address - Phone:989-302-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902011062124Q00000X
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist