Provider Demographics
NPI:1013334291
Name:MAKTABI, OMAR MAZEN (DDS)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:MAZEN
Last Name:MAKTABI
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 1:845 QUARRY RD
Mailing Address - Street 2:#214
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2212
Mailing Address - Country:US
Mailing Address - Phone:909-219-2535
Mailing Address - Fax:
Practice Address - Street 1:2814 NORTHGATE DR STE 1
Practice Address - Street 2:ENDODONTIC ASSOCIATES OF IOWA
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-9513
Practice Address - Country:US
Practice Address - Phone:319-351-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2015-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63245122300000X
IADDS-09255122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist