Healthcare Provider Details

I. General information

NPI: 1659543155
Provider Name (Legal Business Name): JOHN OMALLEY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 RANDOLPH RD
CHARLOTTE NC
28207-1233
US

IV. Provider business mailing address

1928 TRILLIUM LN
CHARLOTTE NC
28211-4445
US

V. Phone/Fax

Practice location:
  • Phone: 704-374-1221
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3852
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: