Provider Demographics
NPI:1649933151
Name:ELKHABBAZ, OMAR HASSAN (DMD)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:HASSAN
Last Name:ELKHABBAZ
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 1:305 MILANO LN APT 207
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8171
Mailing Address - Country:US
Mailing Address - Phone:857-308-8800
Mailing Address - Fax:
Practice Address - Street 1:7777 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7976
Practice Address - Country:US
Practice Address - Phone:321-255-6303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL265101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice