Provider Demographics
NPI:1871595983
Name:IMTIAZ, UMAR M (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:UMAR
Middle Name:M
Last Name:IMTIAZ
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:23374 W YUMA RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-3120
Mailing Address - Country:US
Mailing Address - Phone:623-444-9999
Mailing Address - Fax:623-444-6745
Practice Address - Street 1:23374 W YUMA RD STE 102
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-3120
Practice Address - Country:US
Practice Address - Phone:978-328-2886
Practice Address - Fax:623-444-6745
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0514981223G0001X
AZ72561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ225122Medicaid