Provider Demographics
NPI:1306458740
Name:OMARY, MOHAMMAD WALID (DDS)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:WALID
Last Name:OMARY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MOHAMMAD
Other - Middle Name:WALID
Other - Last Name:OMARY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:17443 ELKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-4432
Mailing Address - Country:US
Mailing Address - Phone:818-674-9233
Mailing Address - Fax:
Practice Address - Street 1:155 W RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-5221
Practice Address - Country:US
Practice Address - Phone:928-669-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0105601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice