Provider Demographics
NPI:1396187019
Name:ISLAS, OMAR
Entity Type:Individual
Prefix:MR
First Name:OMAR
Middle Name:
Last Name:ISLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 N CORONADO ST APT 207
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-4828
Mailing Address - Country:US
Mailing Address - Phone:818-441-3866
Mailing Address - Fax:
Practice Address - Street 1:440 N CORONADO ST UNIT 207
Practice Address - Street 2:
Practice Address - City:LOS A NGELES
Practice Address - State:CA
Practice Address - Zip Code:90026
Practice Address - Country:US
Practice Address - Phone:818-441-3866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67395126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant