Healthcare Provider Details

I. General information

NPI: 1639248719
Provider Name (Legal Business Name): OMAR C CHAHAL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 36 AVE SOUTH
GRAND FORKS ND
58201-6747
US

IV. Provider business mailing address

2845 36 AVE SOUTH
GRAND FORKS ND
58201-6747
US

V. Phone/Fax

Practice location:
  • Phone: 701-775-4444
  • Fax: 701-775-4530
Mailing address:
  • Phone: 701-775-4444
  • Fax: 701-775-4530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1938
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: