Healthcare Provider Details

I. General information

NPI: 1649795063
Provider Name (Legal Business Name): MR. EMAD ELDIN GHALY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W 17TH AVE
EUGENE OR
97402-3619
US

IV. Provider business mailing address

822 NE 181ST AVE
PORTLAND OR
97230-6708
US

V. Phone/Fax

Practice location:
  • Phone: 458-210-3543
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-DO-10126326
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: