Provider Demographics
NPI:1982637807
Name:JAMEL D. ODEH DDS PA
Entity Type:Organization
Organization Name:JAMEL D. ODEH DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:ODEH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-294-2322
Mailing Address - Street 1:4119 WALKER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1315
Mailing Address - Country:US
Mailing Address - Phone:336-294-2322
Mailing Address - Fax:336-294-2323
Practice Address - Street 1:4119 WALKER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1315
Practice Address - Country:US
Practice Address - Phone:336-294-2322
Practice Address - Fax:336-294-2323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC61631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901367Medicaid
NC6996473Medicaid