Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | DN015842 | GA |
N | 1223P0300X | Periodontist | DNCS000514 | GA |
NPI | 1144671397 |
---|---|
Provider Name | Dr. Mira Ghaly |
First Address | Augusta, GA 30912-0001 |
Second Address | Augusta, GA 30912-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2016 |
Last Update Date | 22/10/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00321649A | (05) | GA |