Provider Demographics
NPI:1033771944
Name:KHALIFA, FARIS (DDS)
Entity Type:Individual
Prefix:
First Name:FARIS
Middle Name:
Last Name:KHALIFA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KNEELAND STREET
Mailing Address - Street 2:1419E
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1527
Mailing Address - Country:US
Mailing Address - Phone:617-636-6505
Mailing Address - Fax:617-636-6582
Practice Address - Street 1:1 KNEELAND STREET
Practice Address - Street 2:8TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1527
Practice Address - Country:US
Practice Address - Phone:617-636-6678
Practice Address - Fax:617-636-6582
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2021-05-19
Deactivation Date:2020-02-17
Deactivation Code:
Reactivation Date:2021-05-19
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADL145541223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program