Healthcare Provider Details

I. General information

NPI: 1104780824
Provider Name (Legal Business Name): OMAR ELBARRAG I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 DIMOCK ST
ROXBURY MA
02119-1029
US

IV. Provider business mailing address

9 FORBES ST
JAMAICA PLAIN MA
02130-4858
US

V. Phone/Fax

Practice location:
  • Phone: 617-442-8800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDL101270
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: