Provider Demographics
NPI:1376664888
Name:OMOTO, EMMY (DMD)
Entity Type:Individual
Prefix:
First Name:EMMY
Middle Name:
Last Name:OMOTO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W 68TH ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-5302
Mailing Address - Country:US
Mailing Address - Phone:212-579-8885
Mailing Address - Fax:212-579-8881
Practice Address - Street 1:25 W 68TH ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-5302
Practice Address - Country:US
Practice Address - Phone:212-579-8885
Practice Address - Fax:212-579-8881
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0407161122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist