Provider Demographics
NPI:1750738555
Name:KHOLAKI, OMAR (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:
Last Name:KHOLAKI
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3863 SKY VIEW LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1006
Mailing Address - Country:US
Mailing Address - Phone:818-469-9502
Mailing Address - Fax:
Practice Address - Street 1:2080 CENTURY PARK E STE 610
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2009
Practice Address - Country:US
Practice Address - Phone:424-209-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-21
Last Update Date:2022-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1020621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program