Provider Demographics
NPI:1912679358
Name:ELOUSTAZ, OMAR HARBEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:HARBEY
Last Name:ELOUSTAZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12040 NEENACH ST
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-3043
Mailing Address - Country:US
Mailing Address - Phone:818-579-3351
Mailing Address - Fax:
Practice Address - Street 1:16633 VENTURA BLVD STE 850
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1846
Practice Address - Country:US
Practice Address - Phone:818-990-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS106893122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist