Provider Demographics
NPI:1083782544
Name:LAIJ, KHIN W (DDS)
Entity Type:Individual
Prefix:DR
First Name:KHIN
Middle Name:W
Last Name:LAIJ
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 1:1521 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-3977
Mailing Address - Country:US
Mailing Address - Phone:217-235-5496
Mailing Address - Fax:217-234-6956
Practice Address - Street 1:1521 WABASH AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-3977
Practice Address - Country:US
Practice Address - Phone:217-235-5496
Practice Address - Fax:217-234-6956
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice