Healthcare Provider Details

I. General information

NPI: 1538586136
Provider Name (Legal Business Name): PAMELA OTTESEN DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2014
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1536 JOHN SIMS PKWY
NICEVILLE FL
32578
US

IV. Provider business mailing address

2030 KILDARE CIR
NICEVILLE FL
32578-7308
US

V. Phone/Fax

Practice location:
  • Phone: 850-582-1009
  • Fax:
Mailing address:
  • Phone: 850-582-1009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. PAMELA OTTESEN
Title or Position: DENTIST
Credential: DMD
Phone: 850-582-1009