Provider Demographics
NPI:1598791055
Name:GOTAMCO, VINCENT JOHN LIM (DMD)
Entity Type:Individual
Prefix:
First Name:VINCENT JOHN
Middle Name:LIM
Last Name:GOTAMCO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:VINCENT
Other - Middle Name:JOHN
Other - Last Name:GOTAMCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:3453 BROOKSIDE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-1788
Mailing Address - Country:US
Mailing Address - Phone:209-473-8884
Mailing Address - Fax:209-473-8886
Practice Address - Street 1:3453 BROOKSIDE RD
Practice Address - Street 2:SUITE B
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-1788
Practice Address - Country:US
Practice Address - Phone:209-473-8884
Practice Address - Fax:209-473-8886
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA431641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice