Provider Demographics
NPI:1962291336
Name:OBEIDALLAH, ALA EDDIN OMAR
Entity type:Individual
Prefix:
First Name:ALA EDDIN
Middle Name:OMAR
Last Name:OBEIDALLAH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50634 SILVERTON
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-7703
Mailing Address - Country:US
Mailing Address - Phone:862-374-9067
Mailing Address - Fax:
Practice Address - Street 1:3130 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-4927
Practice Address - Country:US
Practice Address - Phone:269-459-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPENDING122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist