Healthcare Provider Details

I. General information

NPI: 1750738555
Provider Name (Legal Business Name): OMAR KHOLAKI D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2016
Last Update Date: 06/25/2022
Certification Date: 06/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CENTURY PARK E STE 610
LOS ANGELES CA
90067-2009
US

IV. Provider business mailing address

3863 SKY VIEW LN
GLENDALE CA
91214-1006
US

V. Phone/Fax

Practice location:
  • Phone: 424-209-4190
  • Fax:
Mailing address:
  • Phone: 818-469-9502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number102062
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: