Provider Demographics
NPI:1346465051
Name:OKAMOTO, VANCE GARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:VANCE
Middle Name:GARY
Last Name:OKAMOTO
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 1:175 N PENNSYLVANIA AVE #6
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741
Mailing Address - Country:US
Mailing Address - Phone:626-963-4173
Mailing Address - Fax:626-963-6573
Practice Address - Street 1:175 N PENNSYLVANIA AVE #6
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741
Practice Address - Country:US
Practice Address - Phone:626-963-4173
Practice Address - Fax:626-963-6573
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA238591223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA64479OtherINVISALIGN
1681042OtherUNITED CONCORDIA