Provider Demographics
NPI:1043559453
Name:OTA DENTAL CORP
Entity Type:Organization
Organization Name:OTA DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORA
Authorized Official - Middle Name:C
Authorized Official - Last Name:OTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-797-8090
Mailing Address - Street 1:11834 BRYANT ST
Mailing Address - Street 2:#103
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-3815
Mailing Address - Country:US
Mailing Address - Phone:909-797-8090
Mailing Address - Fax:
Practice Address - Street 1:11834 BRYANT ST
Practice Address - Street 2:#103
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-3815
Practice Address - Country:US
Practice Address - Phone:909-797-8090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57849302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA57849Medicaid