Healthcare Provider Details

I. General information

NPI: 1568366110
Provider Name (Legal Business Name): OMER ABDELAZIM BABIKER AHMED BDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 MORTON ST
MATTAPAN MA
02126-2834
US

IV. Provider business mailing address

210 WAREHAM RD APT 4310
PLYMOUTH MA
02360-3673
US

V. Phone/Fax

Practice location:
  • Phone: 617-533-2300
  • Fax:
Mailing address:
  • Phone: 346-697-1390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDL101786
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: