Provider Demographics
NPI:1619035839
Name:OTSU, DARRELL G (DDS DENTIST)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:G
Last Name:OTSU
Suffix:
Gender:M
Credentials:DDS DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 OSBORN
Mailing Address - Street 2:STE 150
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604
Mailing Address - Country:US
Mailing Address - Phone:949-551-2037
Mailing Address - Fax:949-551-9738
Practice Address - Street 1:2 OSBORN
Practice Address - Street 2:STE 150
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604
Practice Address - Country:US
Practice Address - Phone:949-551-2037
Practice Address - Fax:949-551-9738
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice