Healthcare Provider Details

I. General information

NPI: 1346465051
Provider Name (Legal Business Name): VANCE GARY OKAMOTO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 N PENNSYLVANIA AVE #6
GLENDORA CA
91741
US

IV. Provider business mailing address

175 N PENNSYLVANIA AVE #6
GLENDORA CA
91741
US

V. Phone/Fax

Practice location:
  • Phone: 626-963-4173
  • Fax: 626-963-6573
Mailing address:
  • Phone: 626-963-4173
  • Fax: 626-963-6573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number23859
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: