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General NPI Number Information
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NPI Number | 1609176460
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Entity Type | Individual
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Provider Name | KEVIN SHIGERU OMOTO DDS
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Gender | Male
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Dates
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Enumeration Date | 10/27/2010
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Last Update Date | 10/27/2010
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Provider Practice Location Address
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Address Line | 15355 BROOKHURST ST #101
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City | WESTMINSTER
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State | CA
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Zip | 92683-7077
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Country | US
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Telephone | 714-531-5175
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Fax |
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Provider Business Mailing Address
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Address Line | 243 E SANTA FE CT
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City | PLACENTIA
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State | CA
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Zip | 92870-6002
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 58854
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License Number State | CA
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