Provider Demographics
NPI:1053427138
Name:OTSUKA, MERVYN K (DDS)
Entity type:Individual
Prefix:DR
First Name:MERVYN
Middle Name:K
Last Name:OTSUKA
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 1:931 SAN BRUNO AVE W
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-3440
Mailing Address - Country:US
Mailing Address - Phone:650-588-6740
Mailing Address - Fax:
Practice Address - Street 1:931 SAN BRUNO AVE W
Practice Address - Street 2:SUITE 5
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3440
Practice Address - Country:US
Practice Address - Phone:650-588-6740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice