MEDICARE: DR. ALICE M. OTTAVI DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	9919	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	978483	OTHER	MN	UNITED CONCORDIA
2	0015210	OTHER	MN	DORAL DENTAL
3	1727	OTHER	MN	HEALTH PARTNERS
4	46092 DE	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1659393783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALICE M. OTTAVI DDS

Provider Business Mailing Address
First Line	:	2232 HENNEPIN AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2737
Country	:	US
Telephone Number	:	612-377-6108
Fax Number	:	612-374-1820

Provider Business Practice Location Address
First Line	:	2232 HENNEPIN AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2737
Country	:	US
Telephone Number	:	612-377-6108
Fax Number	:	612-374-1820

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/09/2007

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