Provider Demographics
NPI:1760511026
Name:OTA, GARRETT O (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:O
Last Name:OTA
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 1:275 PONAHAWAI ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-3074
Mailing Address - Country:US
Mailing Address - Phone:808-935-2349
Mailing Address - Fax:
Practice Address - Street 1:275 PONAHAWAI ST
Practice Address - Street 2:SUITE 104
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3074
Practice Address - Country:US
Practice Address - Phone:808-935-2349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT18441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI07676801Medicaid