Provider Demographics
NPI:1417981739
Name:GHALI, GHALI ELIAS (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:GHALI
Middle Name:ELIAS
Last Name:GHALI
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118
Mailing Address - Country:US
Mailing Address - Phone:318-212-5254
Mailing Address - Fax:318-212-5257
Practice Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118
Practice Address - Country:US
Practice Address - Phone:318-212-5254
Practice Address - Fax:318-212-5257
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA49981223S0112X, 204E00000X
LA11531R204E00000X, 2086S0122X
LAMD11531R204E00000X
TX15501204E00000X
TXJ8547204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1899496Medicaid
LAG81992Medicare UPIN
LA1899496Medicaid