Provider Demographics
NPI:1760900153
Name:MOUKWA, ELALI ALISHA MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELALI
Middle Name:ALISHA MARIE
Last Name:MOUKWA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 SKIBO RD STE C3
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-1500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1916 SKIBO RD STE C3
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314
Practice Address - Country:US
Practice Address - Phone:910-484-5141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2019-08-01
Deactivation Date:2018-06-29
Deactivation Code:
Reactivation Date:2018-07-18
Provider Licenses
StateLicense IDTaxonomies
NC115251223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program