Anissa R Ottley, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

DN15481 Issued in FL

Practice address

4272 Avalon Blvd
Milton, FL 32583-2808

Phone

(850) 626-6100

Fax

(850) 626-6100

NPI assigned

May 24, 2007

Last updated

Apr 15, 2016By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Dec 15, 2021 through Dec 15, 2027

Medicare enrollment (NPD)

Enrolled

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Avalon Dental Clinic PL

  • General Practice Dentistry
  • Milton, FL
  • NPI 1629045489
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179964800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1460678400000",
    "number": "1013128867",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4272 AVALON BLVD",
            "city": "MILTON",
            "state": "FL",
            "postal_code": "325832808",
            "telephone_number": "850-626-6100",
            "fax_number": "850-626-6100"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4272 AVALON BLVD",
            "city": "MILTON",
            "state": "FL",
            "postal_code": "325832808",
            "telephone_number": "850-626-6100",
            "fax_number": "850-626-6100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "OTTLEY",
        "first_name": "ANISSA",
        "middle_name": "R",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-05-24",
        "last_updated": "2016-04-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "FL",
            "license": "DN15481",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Susan Kay O'Hara
• Tabitha K Odom, LPTA
• Old River Physician Services, LLC
• Makayla A-D Olson
• Carolyn Orsa, RN
• Jeffrey C. Ottley, D.M.D.
• Jerome C Ottley Jr., D.D.S.
• Christina Paccadolmi
• Pace-FL Dental, PA (Aspen Dental)
• Lauren Pace

• General Practice Dentistry in Milton, FL
• Providers in Milton, FL by specialty
• General Practice Dentistry in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 15, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.