Provider Demographics
NPI:1801462866
Name:PROMKET, OSMAN
Entity type:Individual
Prefix:DR
First Name:OSMAN
Middle Name:
Last Name:PROMKET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 VARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-2510
Mailing Address - Country:US
Mailing Address - Phone:978-429-5996
Mailing Address - Fax:
Practice Address - Street 1:161 JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2103
Practice Address - Country:US
Practice Address - Phone:978-937-9700
Practice Address - Fax:978-221-6728
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1859126122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program