Provider Demographics
NPI:1912379017
Name:OMAR, IYAD S (RDH, BS)
Entity Type:Individual
Prefix:
First Name:IYAD
Middle Name:S
Last Name:OMAR
Suffix:
Gender:M
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2702
Mailing Address - Country:US
Mailing Address - Phone:708-425-1134
Mailing Address - Fax:
Practice Address - Street 1:2803 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2702
Practice Address - Country:US
Practice Address - Phone:708-425-1134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020013964124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist