Provider Demographics
NPI:1043552029
Name:OTTO, ALEXANDRA BARTON (DDS)
Entity type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:BARTON
Last Name:OTTO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:BLANCHE
Other - Middle Name:ALEXANDRA
Other - Last Name:BARTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1245 MAIN STREET, BLDG B-2
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BUDA
Mailing Address - State:TX
Mailing Address - Zip Code:78610
Mailing Address - Country:US
Mailing Address - Phone:303-944-8045
Mailing Address - Fax:
Practice Address - Street 1:1245 MAIN STREET, BLDG B-2
Practice Address - Street 2:SUITE 300
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610
Practice Address - Country:US
Practice Address - Phone:303-944-8045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2021831223P0221X
TX315211223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3507097Medicaid