MEDICARE: DR. OLIVIA SUGIMOTO DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	103966	CA

General Provider Information

NPI Number	:	1588216147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLIVIA SUGIMOTO DMD

Provider Business Mailing Address
First Line	:	311 MIKE LOZA DR UNIT 204
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93012-8493
Country	:	US
Telephone Number	:	805-766-3249
Fax Number	:

Provider Business Practice Location Address
First Line	:	5800 SANTA ROSA RD STE 101
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93012-7060
Country	:	US
Telephone Number	:	805-987-8782
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2019
Last Update Date	:	07/14/2019

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