MEDICARE: OMAR HISHAM BAKER SUDQI B.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	46141	CA

General Provider Information

NPI Number	:	1083732010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMAR HISHAM BAKER SUDQI B.D.S.

Provider Business Mailing Address
First Line	:	45104 10TH ST W
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93534-2310
Country	:	US
Telephone Number	:	661-942-2391
Fax Number	:	661-902-6839

Provider Business Practice Location Address
First Line	:	45104 10 TH ST W
Second Line	:	ANTELOPE VALLEY COMMUNITY CLINIC
City	:	LANCASTER
State	:	CA
Zip	:	93534-2310
Country	:	US
Telephone Number	:	661-942-2391
Fax Number	:	661-902-6839

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	01/12/2017

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