Provider Demographics
NPI:1649757386
Name:ALI, OMAR AHMAD (DMD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:AHMAD
Last Name:ALI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LORI CT
Mailing Address - Street 2:
Mailing Address - City:MEDINAH
Mailing Address - State:IL
Mailing Address - Zip Code:60157-9733
Mailing Address - Country:US
Mailing Address - Phone:815-519-0650
Mailing Address - Fax:
Practice Address - Street 1:1120 N MELVIN ST
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-1477
Practice Address - Country:US
Practice Address - Phone:217-784-4251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILTBD122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist