Provider Demographics
NPI:1942934567
Name:CEPERO OMELCHUK, IRINA (DMD)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:CEPERO OMELCHUK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4327 SW 165TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-5287
Mailing Address - Country:US
Mailing Address - Phone:786-205-9721
Mailing Address - Fax:
Practice Address - Street 1:4327 SW 165TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-5287
Practice Address - Country:US
Practice Address - Phone:786-205-9721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN272631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice