=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104780824
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OMAR ELBARRAG I
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2025
-----------------------------------------------------
Last Update Date | 12/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 DIMOCK ST
-----------------------------------------------------
City | ROXBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02119-1029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-442-8800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 FORBES ST
-----------------------------------------------------
City | JAMAICA PLAIN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02130-4858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DL101270
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------