Provider Demographics
NPI:1356033252
Name:OMAR ELOUSTAZ DENTAL CORPORATION
Entity type:Organization
Organization Name:OMAR ELOUSTAZ DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:HARBEY
Authorized Official - Last Name:ELOUSTAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-579-3351
Mailing Address - Street 1:12040 NEENACH ST
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-3043
Mailing Address - Country:US
Mailing Address - Phone:818-579-3351
Mailing Address - Fax:
Practice Address - Street 1:16633 VENTURA BLVD STE 850
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1846
Practice Address - Country:US
Practice Address - Phone:818-990-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental