Provider Demographics
NPI:1366992034
Name:ABUSTEIT, OMAR EZZALDIN
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:EZZALDIN
Last Name:ABUSTEIT
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 1:40 W NICOLLET BLVD
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4524
Mailing Address - Country:US
Mailing Address - Phone:952-746-4519
Mailing Address - Fax:
Practice Address - Street 1:40 W NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4524
Practice Address - Country:US
Practice Address - Phone:952-746-4519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNS1151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics