Provider Demographics
NPI:1851695639
Name:OTA, KAZUO (DDS)
Entity Type:Individual
Prefix:DR
First Name:KAZUO
Middle Name:
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 1:3400 LOMITA BLVD
Mailing Address - Street 2:SUITE 504
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4909
Mailing Address - Country:US
Mailing Address - Phone:310-784-2777
Mailing Address - Fax:
Practice Address - Street 1:3400 LOMITA BLVD
Practice Address - Street 2:SUITE 504
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4909
Practice Address - Country:US
Practice Address - Phone:310-784-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-07
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36406122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry