1104088491 NPI number — OMNI DENTIX & ASSOC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104088491 NPI number — OMNI DENTIX & ASSOC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMNI DENTIX & ASSOC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104088491
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3850 MYSTIC VALLEY PKWY
Provider Second Line Business Mailing Address:
SUITE 20
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02155-6901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-396-6613
Provider Business Mailing Address Fax Number:
781-395-4292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3850 MYSTIC VALLEY PKWY
Provider Second Line Business Practice Location Address:
SUITE 20
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155-6901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-396-6613
Provider Business Practice Location Address Fax Number:
781-395-4292
Provider Enumeration Date:
06/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MOBASHERAT
Authorized Official First Name:
MOHAMMED
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
781-396-6613

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  20309 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 15376 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223X0400X , with the licence number: 13913 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0263702 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0205401 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0268361 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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