Provider Demographics
NPI:1083831895
Name:KHAN, MOHAMMAD RAFI
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:RAFI
Last Name:KHAN
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 1:105 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4967
Mailing Address - Country:US
Mailing Address - Phone:630-853-3478
Mailing Address - Fax:773-947-8664
Practice Address - Street 1:1952 EAST 73 STREE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649
Practice Address - Country:US
Practice Address - Phone:773-947-8664
Practice Address - Fax:773-947-8664
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist