Healthcare Provider Details

I. General information

NPI: 1104093533
Provider Name (Legal Business Name): PATRICK KEIJI OHARA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E BEVERLY BLVD SUITE 103
MONTEBELLO CA
90640-7001
US

IV. Provider business mailing address

200 E BEVERLY BLVD SUITE 103
MONTEBELLO CA
90640-7001
US

V. Phone/Fax

Practice location:
  • Phone: 323-888-1192
  • Fax: 323-888-2009
Mailing address:
  • Phone: 323-888-1192
  • Fax: 323-888-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number34535
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: