Basic Information
| Provider Information | |||||||||
| NPI: | 1588734297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHONEIM | ||||||||
| FirstName: | OMAR | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1135 MORTON STREET | ||||||||
| Address2: | |||||||||
| City: | MATTAPAN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021262834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175332300 | ||||||||
| FaxNumber: | 6175332341 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 MOUNT VERNON STREET | ||||||||
| Address2: | |||||||||
| City: | DORCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172881140 | ||||||||
| FaxNumber: | 6172883910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 04/18/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 019023860 | IL | N | Dental Providers | Dentist | 122300000X | 21879 | MA | Y | Dental Providers | Dentist |
No ID Information.