=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831590231
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ODETA PETRI DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2014
-----------------------------------------------------
Last Update Date | 11/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2231 S BRISTOL ST
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92704-5124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-556-1001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3700 S PLAZA DR #KPH2
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92704-7434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-610-8388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 63838
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------