=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346447711
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMARI ONYANGO DDS A PROFESSIONAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2007
-----------------------------------------------------
Last Update Date | 06/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12384 PALMDALE RD 204
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92392-8506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-843-5400
-----------------------------------------------------
Fax | 760-843-5465
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12384 PALMDALE RD. # 204
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-843-5400
-----------------------------------------------------
Fax | 760-843-5465
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. OMARI ONYANGO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 760-843-5400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 54183
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------