Provider Demographics
NPI:1972345981
Name:OMALLEY, PAUL JEROME (SOLE PROPRIETOR)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JEROME
Last Name:OMALLEY
Suffix:
Gender:M
Credentials:SOLE PROPRIETOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16661 VENTURA BLVD STE 800
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4821
Mailing Address - Country:US
Mailing Address - Phone:818-324-3352
Mailing Address - Fax:
Practice Address - Street 1:16661 VENTURA BLVD STE 800
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4821
Practice Address - Country:US
Practice Address - Phone:818-324-3352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS476521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice