Provider Demographics
NPI:1164574208
Name:OMORI, MITCHELL DWIGHT (DDS)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DWIGHT
Last Name:OMORI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LAKE COOK RD
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015
Mailing Address - Country:US
Mailing Address - Phone:847-945-8565
Mailing Address - Fax:847-945-8278
Practice Address - Street 1:400 LAKE COOK RD
Practice Address - Street 2:SUITE 200A
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015
Practice Address - Country:US
Practice Address - Phone:847-945-8565
Practice Address - Fax:847-945-8278
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist