Provider Demographics
NPI:1780994533
Name:ELBANHAWY, OMAR E (DDS, MS)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:E
Last Name:ELBANHAWY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 WOODS LN
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1160
Mailing Address - Country:US
Mailing Address - Phone:410-982-8440
Mailing Address - Fax:
Practice Address - Street 1:561 WOODS LN
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48236-1160
Practice Address - Country:US
Practice Address - Phone:410-982-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014129101223P0300X
MI29010210201223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics