Provider Demographics
NPI:1598311755
Name:MOHAMED, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:MOHAMED
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 1:125 LONG HILL RD APT 4D
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-2332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1245 WHITEHORSE MERCERVILLE RD # A-417
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-3831
Practice Address - Country:US
Practice Address - Phone:609-581-4322
Practice Address - Fax:609-581-8220
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI02772000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist