Provider Demographics
NPI:1609176460
Name:OMOTO, KEVIN SHIGERU (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:SHIGERU
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 1:243 E SANTA FE CT
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-6002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15355 BROOKHURST ST
Practice Address - Street 2:#101
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-7077
Practice Address - Country:US
Practice Address - Phone:714-531-5175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58854122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist