Healthcare Provider Details

I. General information

NPI: 1578894820
Provider Name (Legal Business Name): SUZANNE K OTTO DENTAL HYGENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4536 22ND AVE
KENOSHA WI
53140-5917
US

IV. Provider business mailing address

4536 22ND AVE
KENOSHA WI
53140-5917
US

V. Phone/Fax

Practice location:
  • Phone: 262-656-0044
  • Fax: 262-653-2218
Mailing address:
  • Phone: 262-656-0044
  • Fax: 262-653-2218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020.012262
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number10133-16
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: