Provider Demographics
NPI:1265010847
Name:GARCIA, OMAR (DMD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:GARCIA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:OMAR
Other - Middle Name:GUILLERMO
Other - Last Name:GARCIA CHACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:919 HILLCREST DR APT 801
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-7883
Mailing Address - Country:US
Mailing Address - Phone:954-805-1908
Mailing Address - Fax:
Practice Address - Street 1:257 PLAINFIELD RD
Practice Address - Street 2:
Practice Address - City:WEST LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03784-2026
Practice Address - Country:US
Practice Address - Phone:954-805-1908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NH04745122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program