Provider Demographics
NPI:1902012453
Name:LOS ALAMITOS ENDODONTICS DENTAL PRACTICE OF POLK AND LIVINGFORD
Entity Type:Organization
Organization Name:LOS ALAMITOS ENDODONTICS DENTAL PRACTICE OF POLK AND LIVINGFORD
Other - Org Name:LAWRENCE H. OTA, DDS & AILEEN E. JITSUMYO, DDS A PROFESSIONAL CORPORAT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:LIVINGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-596-1664
Mailing Address - Street 1:3551 FARQUHAR AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2003
Mailing Address - Country:US
Mailing Address - Phone:562-596-1664
Mailing Address - Fax:562-431-5934
Practice Address - Street 1:3551 FARQUHAR AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2003
Practice Address - Country:US
Practice Address - Phone:562-596-1664
Practice Address - Fax:562-431-5934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA274711223E0200X
CA313611223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty