Provider Demographics
NPI:1780104117
Name:RAGAB, OMAR IBRAHIM (DMD)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:IBRAHIM
Last Name:RAGAB
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 1:3464 HONEYSUCKLE CT
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-8856
Mailing Address - Country:US
Mailing Address - Phone:201-515-0296
Mailing Address - Fax:
Practice Address - Street 1:2429 ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-4853
Practice Address - Country:US
Practice Address - Phone:734-434-0043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010223681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901022368OtherMICHIGAN PROFESSION AND LICENSE