Healthcare Provider Details

I. General information

NPI: 1992093454
Provider Name (Legal Business Name): OMAR CHACON D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 SW 97TH ST
PINECREST FL
33156-2058
US

IV. Provider business mailing address

511 6TH ST APT 4B
BROOKLYN NY
11215-3668
US

V. Phone/Fax

Practice location:
  • Phone: 787-731-6622
  • Fax:
Mailing address:
  • Phone: 787-614-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN25563
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: