Provider Demographics
NPI:1023406139
Name:HUSSAIN, OMAR
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:HUSSAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 YORKSHIRE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-2894
Mailing Address - Country:US
Mailing Address - Phone:828-820-5180
Mailing Address - Fax:
Practice Address - Street 1:11 YORKSHIRE ST STE 101
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-2894
Practice Address - Country:US
Practice Address - Phone:828-820-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-26
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10012781223S0112X
NC125701223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1023406139Medicaid