Provider Demographics
NPI:1043519416
Name:OMAR T COCKEY DMD PA
Entity type:Organization
Organization Name:OMAR T COCKEY DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:T
Authorized Official - Last Name:COCKEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-779-6183
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-0115
Mailing Address - Country:US
Mailing Address - Phone:973-779-6183
Mailing Address - Fax:973-779-6183
Practice Address - Street 1:703 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2621
Practice Address - Country:US
Practice Address - Phone:973-779-6183
Practice Address - Fax:973-779-6183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI 17684261Q00000X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4608909Medicaid