MEDICARE: DAIKI A. OTSUKA, DDS, PA

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	122300000X	Dentist

General Provider Information

NPI Number	:	1083827257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAIKI A. OTSUKA, DDS, PA

Provider Business Mailing Address
First Line	:	1617 PARKER AVE
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-6950
Country	:	US
Telephone Number	:	201-461-0130
Fax Number	:	201-461-8525

Provider Business Practice Location Address
First Line	:	1617 PARKER AVE
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-6950
Country	:	US
Telephone Number	:	201-461-0130
Fax Number	:	201-461-8525

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ELAINE SUMIRE OTSUKA
Credential	:	DMD
Telephone Number	:	201-461-0130

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	08/22/2020

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