Provider Demographics
NPI:1407817208
Name:OMOTO, THOMAS TERUMI (DMD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:TERUMI
Last Name:OMOTO
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 1:927 DEEP VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-3836
Mailing Address - Country:US
Mailing Address - Phone:310-377-0929
Mailing Address - Fax:310-377-0794
Practice Address - Street 1:927 DEEP VALLEY DR
Practice Address - Street 2:
Practice Address - City:ROLLING HILLS ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-3808
Practice Address - Country:US
Practice Address - Phone:310-377-0929
Practice Address - Fax:310-377-0794
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU17260Medicare UPIN