Provider Demographics
NPI:1679139521
Name:ELHASSADI, OMAR (BDS, FFD, MSC)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:ELHASSADI
Suffix:
Gender:M
Credentials:BDS, FFD, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:509-444-7806
Practice Address - Street 1:844 6TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403
Practice Address - Country:US
Practice Address - Phone:208-848-8300
Practice Address - Fax:208-848-8306
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60915436122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty