Healthcare Provider Details

I. General information

NPI: 1053937086
Provider Name (Legal Business Name): OMAR ABDELRAHMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 08/01/2021
Certification Date: 08/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST RM 2D
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4266
  • Fax:
Mailing address:
  • Phone: 313-745-4697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2901601045
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: