MEDICARE: DR. OMAR KHOLAKI D.D.S., M.D.

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	102062	CA

General Provider Information

NPI Number	:	1750738555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OMAR KHOLAKI D.D.S., M.D.

Provider Business Mailing Address
First Line	:	3863 SKY VIEW LN
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91214-1006
Country	:	US
Telephone Number	:	818-469-9502
Fax Number	:

Provider Business Practice Location Address
First Line	:	2080 CENTURY PARK E STE 610
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90067-2009
Country	:	US
Telephone Number	:	424-209-4190
Fax Number	:

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

Provider Enumeration Date	:	05/21/2016
Last Update Date	:	06/25/2022

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