Provider Demographics
NPI:1861663148
Name:CHONG, OTIS T (DMD)
Entity Type:Individual
Prefix:DR
First Name:OTIS
Middle Name:T
Last Name:CHONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30190 TOWN CENTER DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677
Mailing Address - Country:US
Mailing Address - Phone:949-363-2540
Mailing Address - Fax:949-363-3352
Practice Address - Street 1:30190 TOWN CENTER DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677
Practice Address - Country:US
Practice Address - Phone:949-363-2540
Practice Address - Fax:949-363-3352
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215521122300000X
CA563851223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist