Provider Demographics
NPI:1558394007
Name:PAREDES, OMAR R (DDS)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:R
Last Name:PAREDES
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:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:252-744-3258
Mailing Address - Fax:252-744-3194
Practice Address - Street 1:600 MOYE BLVD
Practice Address - Street 2:FAMILY MEDICINE DENTAL CLINIC
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:252-744-4618
Practice Address - Fax:252-744-2827
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903390Medicaid
NCV08207Medicare UPIN
NC5903390Medicaid