Provider Demographics
NPI:1588216147
Name:SUGIMOTO, OLIVIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:
Last Name:SUGIMOTO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:
Other - Last Name:DONALDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:311 MIKE LOZA DR UNIT 204
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8493
Mailing Address - Country:US
Mailing Address - Phone:805-766-3249
Mailing Address - Fax:
Practice Address - Street 1:5800 SANTA ROSA RD STE 101
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-7060
Practice Address - Country:US
Practice Address - Phone:805-987-8782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-14
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1039661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice