Provider Demographics
NPI:1366516023
Name:OTA, BLAIR GREGORY (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:GREGORY
Last Name:OTA
Suffix:
Gender:M
Credentials:DDS, MD
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Mailing Address - Street 1:4980 BARRANCA PKWY STE 190
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-8652
Mailing Address - Country:US
Mailing Address - Phone:949-453-9797
Mailing Address - Fax:
Practice Address - Street 1:4980 BARRANCA PKWY STE 190
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-8652
Practice Address - Country:US
Practice Address - Phone:949-453-9797
Practice Address - Fax:949-872-2468
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA241591223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG48916AMedicare ID - Type UnspecifiedMEDICARE
CAG48916Medicare UPIN