Provider Demographics
NPI:1467495069
Name:OGHALAI, MARK ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:OGHALAI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 WESTGATE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2995
Mailing Address - Country:US
Mailing Address - Phone:336-765-5374
Mailing Address - Fax:336-760-3066
Practice Address - Street 1:1405 WESTGATE CENTER DR
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2995
Practice Address - Country:US
Practice Address - Phone:336-765-5374
Practice Address - Fax:336-760-3066
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC68541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902EYMedicaid
NC89902EYOtherBCBS
NC2428894Medicare ID - Type Unspecified
NCU94388Medicare UPIN