Provider Demographics
NPI:1992093454
Name:CHACON, OMAR (DMD)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:
Last Name:CHACON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 6TH ST APT 4B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3668
Mailing Address - Country:US
Mailing Address - Phone:787-614-5000
Mailing Address - Fax:
Practice Address - Street 1:5700 SW 97TH ST
Practice Address - Street 2:
Practice Address - City:PINECREST
Practice Address - State:FL
Practice Address - Zip Code:33156-2058
Practice Address - Country:US
Practice Address - Phone:787-731-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN255631223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program