Healthcare Provider Details

I. General information

NPI: 1467495069
Provider Name (Legal Business Name): MARK ALAN OGHALAI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 WESTGATE CENTER DR
WINSTON-SALEM NC
27103-2995
US

IV. Provider business mailing address

1405 WESTGATE CENTER DR
WINSTON-SALEM NC
27103-2995
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-5374
  • Fax: 336-760-3066
Mailing address:
  • Phone: 336-765-5374
  • Fax: 336-760-3066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6854
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: