Healthcare Provider Details

I. General information

NPI: 1265301642
Provider Name (Legal Business Name): OTSEGO FAMILY DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 W ALLEGAN ST
OTSEGO MI
49078-1012
US

IV. Provider business mailing address

338 W ALLEGAN ST
OTSEGO MI
49078-1012
US

V. Phone/Fax

Practice location:
  • Phone: 269-694-2074
  • Fax:
Mailing address:
  • Phone: 269-694-2074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN M HIMMEL
Title or Position: MEMBER
Credential: DDS
Phone: 269-364-5137