Provider Demographics
NPI:1043385768
Name:KHAN, FAISAL ALI (DDS)
Entity Type:Individual
Prefix:
First Name:FAISAL
Middle Name:ALI
Last Name:KHAN
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 1:4435 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2625
Mailing Address - Country:US
Mailing Address - Phone:708-423-5992
Mailing Address - Fax:708-423-8552
Practice Address - Street 1:4435 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2625
Practice Address - Country:US
Practice Address - Phone:708-423-5992
Practice Address - Fax:708-423-8552
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019237122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist