Provider Demographics
NPI:1952582827
Name:DE OLIVEIRA, OMAR GUSTAVO (DDS)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:GUSTAVO
Last Name:DE OLIVEIRA
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 1:11110 MEDICAL CAMPUS RD STE 148
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6755
Mailing Address - Country:US
Mailing Address - Phone:240-313-9660
Mailing Address - Fax:240-313-9661
Practice Address - Street 1:11110 MEDICAL CAMPUS RD STE 148
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6755
Practice Address - Country:US
Practice Address - Phone:240-313-9660
Practice Address - Fax:240-313-9661
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14269122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist