Basic Information
Provider Information | |||||||||
NPI: | 1336346196 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KHAN | ||||||||
FirstName: | MIR | ||||||||
MiddleName: | MA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 620 COUNTRY CLUB APTS | ||||||||
Address2: | ROUTE 309 N | ||||||||
City: | DALLAS | ||||||||
State: | PA | ||||||||
PostalCode: | 186128925 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2154312000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1111 E END BLVD | ||||||||
Address2: | VAMC MEDICAL CENTER DENTAL SERVICE | ||||||||
City: | WILKES BARRE | ||||||||
State: | PA | ||||||||
PostalCode: | 187110030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5708243521 | ||||||||
FaxNumber: | 5708195153 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 052574-1 | NY | Y |   | Dental Providers | Dentist |   |
No ID Information.