Provider Demographics
NPI:1992917389
Name:OUMNOV, SERGEY (DDS)
Entity type:Individual
Prefix:
First Name:SERGEY
Middle Name:
Last Name:OUMNOV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 BIRCH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-1398
Mailing Address - Country:US
Mailing Address - Phone:650-365-5546
Mailing Address - Fax:650-364-7776
Practice Address - Street 1:114 BIRCH ST
Practice Address - Street 2:SUITE C
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-1398
Practice Address - Country:US
Practice Address - Phone:650-365-5546
Practice Address - Fax:650-364-7776
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42390122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA42390OtherLICENSE
CAB42390 01OtherMEDI CAL PROVIDER NUMBER
CA42390OtherLICENSE