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General NPI Number Information
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NPI Number | 1588734297
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Entity Type | Individual
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Provider Name | OMAR L GHONEIM DDS
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Gender | Male
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 04/18/2011
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Provider Practice Location Address
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Address Line | 250 MOUNT VERNON STREET
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City | DORCHESTER
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State | MA
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Zip | 02125
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Country | US
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Telephone | 617-288-1140
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Fax | 617-288-3910
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Provider Business Mailing Address
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Address Line | 1135 MORTON STREET
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City | MATTAPAN
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State | MA
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Zip | 02126-2834
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Country | US
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Telephone | 617-533-2300
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Fax | 617-533-2341
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019023860
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 21879
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License Number State | MA
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