Individual
OMID KHAKSARFARD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
6035 DURAND AVE, MT PLEASANT, WI 53406-5049
(262) 270-6933
Mailing address
233 LAKE AVE APT 228, RACINE, WI 53403-1045
(571) 430-0432
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
6001855
WI
Other
Enumeration date
10/09/2024
Last updated
10/05/2025
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