Basic Information
| Provider Information | |||||||||
| NPI: | 1598965899 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IMROZ | ||||||||
| FirstName: | KHALEDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810033111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195624461 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3439 MCGEHEE RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361113392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342881868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2007 | ||||||||
| LastUpdateDate: | 07/24/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 5541 | AL | Y | Dental Providers | Dentist | General Practice |
No ID Information.