Provider Demographics
NPI:1346356045
Name:OTOMO-CORGEL, JOAN (DDS, MPH)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:
Last Name:OTOMO-CORGEL
Suffix:
Gender:F
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 MANHATTAN AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2051
Mailing Address - Country:US
Mailing Address - Phone:310-546-3239
Mailing Address - Fax:310-545-4485
Practice Address - Street 1:1127 WILSHIRE BLVD
Practice Address - Street 2:SUITE #1110
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3901
Practice Address - Country:US
Practice Address - Phone:213-481-0664
Practice Address - Fax:213-481-2902
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA257541223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics