Provider Demographics
NPI:1376700336
Name:MEHDIPOUR, OMID (DDS)
Entity Type:Individual
Prefix:
First Name:OMID
Middle Name:
Last Name:MEHDIPOUR
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 1:901 NORTH PENN STREET
Mailing Address - Street 2:R-2101
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123
Mailing Address - Country:US
Mailing Address - Phone:202-758-9707
Mailing Address - Fax:
Practice Address - Street 1:7900 OLD YORK RD
Practice Address - Street 2:#108A
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-2318
Practice Address - Country:US
Practice Address - Phone:215-635-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0390861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics