Provider Demographics
NPI:1104088491
Name:OMNI DENTIX & ASSOC.
Entity type:Organization
Organization Name:OMNI DENTIX & ASSOC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOBASHERAT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, DDS,
Authorized Official - Phone:781-396-6613
Mailing Address - Street 1:3850 MYSTIC VALLEY PKWY
Mailing Address - Street 2:SUITE 20
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6901
Mailing Address - Country:US
Mailing Address - Phone:781-396-6613
Mailing Address - Fax:781-395-4292
Practice Address - Street 1:3850 MYSTIC VALLEY PKWY
Practice Address - Street 2:SUITE 20
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-6901
Practice Address - Country:US
Practice Address - Phone:781-396-6613
Practice Address - Fax:781-395-4292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA203091223G0001X
MA139131223X0400X
MA153761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0263702Medicaid
MA0205401Medicaid
MA0268361Medicaid