Provider Demographics
NPI:1053301465
Name:KHALIFA, SABAH H (DDS)
Entity Type:Individual
Prefix:
First Name:SABAH
Middle Name:H
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 1:1229 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2204
Mailing Address - Country:US
Mailing Address - Phone:773-252-5772
Mailing Address - Fax:773-278-0543
Practice Address - Street 1:1229 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2204
Practice Address - Country:US
Practice Address - Phone:773-252-5772
Practice Address - Fax:773-278-0543
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1915779122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1002504Medicaid