Provider Demographics
NPI:1184095028
Name:OMAR, HAMZA
Entity type:Individual
Prefix:
First Name:HAMZA
Middle Name:
Last Name:OMAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 S RAVINIA DR
Mailing Address - Street 2:APT 202
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-5738
Mailing Address - Country:US
Mailing Address - Phone:414-377-2563
Mailing Address - Fax:
Practice Address - Street 1:4240 S RAVINIA DR
Practice Address - Street 2:APT 202
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-5738
Practice Address - Country:US
Practice Address - Phone:414-377-2563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001185-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist