Provider Demographics
NPI:1043863038
Name:DERMOUMI, KHALID SKY
Entity Type:Individual
Prefix:
First Name:KHALID
Middle Name:SKY
Last Name:DERMOUMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ALBERT PL
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-3915
Mailing Address - Country:US
Mailing Address - Phone:201-932-8437
Mailing Address - Fax:
Practice Address - Street 1:1 ALBERT PL
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305-3915
Practice Address - Country:US
Practice Address - Phone:201-932-8437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI027666001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice