Provider Demographics
NPI:1497849103
Name:GUERRA, OMAR I (DDS)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:I
Last Name:GUERRA
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 1:1305 WONDER WORLD DR.
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666
Mailing Address - Country:US
Mailing Address - Phone:512-396-3727
Mailing Address - Fax:512-878-2403
Practice Address - Street 1:1305 WONDER WORLD DR.
Practice Address - Street 2:SUITE 303
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666
Practice Address - Country:US
Practice Address - Phone:512-396-3727
Practice Address - Fax:512-878-2403
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX168361223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120875303Medicaid