Provider Demographics
NPI:1295350213
Name:OMEISHI, MOHAMMED (DMD)
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:OMEISHI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 S LAFLIN ST APT 203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4621
Mailing Address - Country:US
Mailing Address - Phone:832-732-7528
Mailing Address - Fax:
Practice Address - Street 1:3014 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-5805
Practice Address - Country:US
Practice Address - Phone:832-732-7528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist