Provider Demographics
NPI:1376692186
Name:OMOTO, LESLIE MASAO (DDS)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:MASAO
Last Name:OMOTO
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 1:4473 PAHEE ST STE S
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-2037
Mailing Address - Country:US
Mailing Address - Phone:808-246-0024
Mailing Address - Fax:808-246-0212
Practice Address - Street 1:4473 PAHEE ST STE S
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-2037
Practice Address - Country:US
Practice Address - Phone:808-246-0024
Practice Address - Fax:808-246-0212
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-17511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice