Healthcare Provider Details

I. General information

NPI: 1982194205
Provider Name (Legal Business Name): ODY ZOMA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ODAY ZUMA

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2094 E HIGHLAND AVE
SAN BERNARDINO CA
92404-4626
US

IV. Provider business mailing address

821 N WILCOX AVE APT 226
MONTEBELLO CA
90640-1849
US

V. Phone/Fax

Practice location:
  • Phone: 909-388-2427
  • Fax:
Mailing address:
  • Phone: 248-565-6345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number102425
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD15009
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: