Provider Demographics
NPI:1679302624
Name:YAACOOBI, OMAR MOHAMMAD (DMD)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:MOHAMMAD
Last Name:YAACOOBI
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 1:1792 CLAYCORD AVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-2112
Mailing Address - Country:US
Mailing Address - Phone:703-965-8560
Mailing Address - Fax:
Practice Address - Street 1:2410 SAN RAMON VALLEY BLVD STE 148
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1672
Practice Address - Country:US
Practice Address - Phone:925-855-1604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110368122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist