Healthcare Provider Details

I. General information

NPI: 1164979464
Provider Name (Legal Business Name): SCOTT WILLIAM OTTERSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 CLARK RD, BLDG 339 USA DENTAL HEALTH ACTIVITY
FT SHAFTER HI
96858
US

IV. Provider business mailing address

6479 W CARRICK WAY
HIGHLAND UT
84003-5526
US

V. Phone/Fax

Practice location:
  • Phone: 808-438-3990
  • Fax:
Mailing address:
  • Phone: 610-202-5735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12667815-8903
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD-5561-EN
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12667815-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: