Provider Demographics
NPI:1619316064
Name:ANSARI, OMAR (DDS)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:ANSARI
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 1:28282 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-5604
Mailing Address - Country:US
Mailing Address - Phone:586-574-2620
Mailing Address - Fax:586-574-3015
Practice Address - Street 1:28282 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-5604
Practice Address - Country:US
Practice Address - Phone:586-574-2620
Practice Address - Fax:586-574-3015
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020901122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist