Provider Demographics
NPI:1801142328
Name:OMRAN, MOHAMEDTAREK A (BDS)
Entity type:Individual
Prefix:
First Name:MOHAMEDTAREK
Middle Name:A
Last Name:OMRAN
Suffix:
Gender:M
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 SPYGLASS CT
Mailing Address - Street 2:APT B
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3672
Mailing Address - Country:US
Mailing Address - Phone:314-546-5628
Mailing Address - Fax:
Practice Address - Street 1:2800 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4742
Practice Address - Country:US
Practice Address - Phone:618-474-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028913122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist