Healthcare Provider Details

I. General information

NPI: 1568949337
Provider Name (Legal Business Name): KHALED ALSHARIF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 SUNCREST TOWN CENTRE DR
MORGANTOWN WV
26505-1814
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-6208
  • Fax:
Mailing address:
  • Phone: 304-293-6208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401416206
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: