Healthcare Provider Details

I. General information

NPI: 1659167161
Provider Name (Legal Business Name): OMER KASSIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 W PERKINS AVE
SANDUSKY OH
44870-4802
US

IV. Provider business mailing address

129 W PERKINS AVE
SANDUSKY OH
44870-4802
US

V. Phone/Fax

Practice location:
  • Phone: 419-901-0488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.028388
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: