Provider Demographics
NPI:1104518083
Name:AL AZZAWI, OMAR (DDS)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:
Last Name:AL AZZAWI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17132 SEABOARD PL
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-0125
Mailing Address - Country:US
Mailing Address - Phone:347-327-0831
Mailing Address - Fax:
Practice Address - Street 1:1537 S SCATTERFIELD RD STE A
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-5783
Practice Address - Country:US
Practice Address - Phone:765-347-7722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014066A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist