Provider Demographics
NPI:1710067657
Name:ODOMO, WATARU (DDS)
Entity Type:Individual
Prefix:DR
First Name:WATARU
Middle Name:
Last Name:ODOMO
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 1:1431 SARATOGA AVE APT 335
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-4457
Mailing Address - Country:US
Mailing Address - Phone:408-446-0829
Mailing Address - Fax:
Practice Address - Street 1:18805 COX AVE STE 100
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-4183
Practice Address - Country:US
Practice Address - Phone:408-866-1344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31839122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist