Provider Demographics
NPI:1689079501
Name:OTANI, STEVEN MIKKIO (DDS)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:MIKKIO
Last Name:OTANI
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 1:618 LINCOLN CTR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-2639
Mailing Address - Country:US
Mailing Address - Phone:209-478-0568
Mailing Address - Fax:209-478-0568
Practice Address - Street 1:618 LINCOLN CTR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-2639
Practice Address - Country:US
Practice Address - Phone:209-478-0568
Practice Address - Fax:209-478-0568
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA345381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice