Healthcare Provider Details

I. General information

NPI: 1366604761
Provider Name (Legal Business Name): OMAID K AHMAD BDS MDSC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BROADVIEW DR
GREEN BAY WI
54301-2805
US

IV. Provider business mailing address

111 BROADVIEW DR
GREEN BAY WI
54301-2805
US

V. Phone/Fax

Practice location:
  • Phone: 920-437-1499
  • Fax:
Mailing address:
  • Phone: 920-437-1499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number1001274
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: