Provider Demographics
NPI:1396397634
Name:ALBASHA, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:ALBASHA
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 1:215 HOOVER WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1044
Mailing Address - Country:US
Mailing Address - Phone:201-519-7399
Mailing Address - Fax:
Practice Address - Street 1:12165 ELM ST
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-1358
Practice Address - Country:US
Practice Address - Phone:410-651-5151
Practice Address - Fax:410-651-4256
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02761700122300000X
MD179671223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid