Provider Demographics
NPI:1255357893
Name:THOMAS T. OMOTO, DMD INC
Entity type:Organization
Organization Name:THOMAS T. OMOTO, DMD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:T
Authorized Official - Last Name:OMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:310-325-7800
Mailing Address - Street 1:3445 PACIFIC COAST HWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505
Mailing Address - Country:US
Mailing Address - Phone:310-325-7800
Mailing Address - Fax:310-325-7804
Practice Address - Street 1:3445 PACIFIC COAST HWY
Practice Address - Street 2:SUITE 205
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505
Practice Address - Country:US
Practice Address - Phone:310-325-7800
Practice Address - Fax:310-325-7804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31506261QD0000X
204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU17260Medicare UPIN