Provider Demographics
NPI:1740016088
Name:MOUSTAFA, OMAR HMS (BDS, MSC, MS, FRCDC)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:HMS
Last Name:MOUSTAFA
Suffix:
Gender:M
Credentials:BDS, MSC, MS, FRCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S PRESTON ST OFC 68
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1701
Mailing Address - Country:US
Mailing Address - Phone:614-886-7609
Mailing Address - Fax:
Practice Address - Street 1:501 S PRESTON ST OFC 58
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1701
Practice Address - Country:US
Practice Address - Phone:614-886-7609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY111691223G0001X
KY12141223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice