Provider Demographics
NPI:1174976831
Name:ODA, MARIKO CHOETSOPON (DMD)
Entity type:Individual
Prefix:DR
First Name:MARIKO
Middle Name:CHOETSOPON
Last Name:ODA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 HONEY GLEN WAY
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-0124
Mailing Address - Country:US
Mailing Address - Phone:912-577-5404
Mailing Address - Fax:
Practice Address - Street 1:3640 HONEY GLEN WAY
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-0124
Practice Address - Country:US
Practice Address - Phone:912-577-5404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS100412122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist