Provider Demographics
NPI:1093441461
Name:KHAN'S TELEDENTISTY
Entity Type:Organization
Organization Name:KHAN'S TELEDENTISTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-747-4360
Mailing Address - Street 1:1200 RENEE CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5815
Mailing Address - Country:US
Mailing Address - Phone:910-747-4360
Mailing Address - Fax:
Practice Address - Street 1:1200 RENEE CT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-5815
Practice Address - Country:US
Practice Address - Phone:910-747-4360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC41808696Medicaid