Healthcare Provider Details

I. General information

NPI: 1740040682
Provider Name (Legal Business Name): OMNI ON PREMISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 LONG BEACH BLVD STE D5
LONG BEACH CA
90805-6976
US

IV. Provider business mailing address

4647 LONG BEACH BLVD STE D5
LONG BEACH CA
90805-6976
US

V. Phone/Fax

Practice location:
  • Phone: 562-453-0525
  • Fax: 562-980-0020
Mailing address:
  • Phone: 562-453-0525
  • Fax: 562-980-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER DOANE
Title or Position: DOCTOR
Credential: DDS
Phone: 805-450-7329