Provider Demographics
NPI:1144419433
Name:KHEIRALLA, MOHAMMAD A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:A
Last Name:KHEIRALLA
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 1:73 SUNSET STRIP
Mailing Address - Street 2:
Mailing Address - City:SUCCASUNNA
Mailing Address - State:NJ
Mailing Address - Zip Code:07876-1311
Mailing Address - Country:US
Mailing Address - Phone:973-584-8447
Mailing Address - Fax:
Practice Address - Street 1:73 SUNSET STRIP
Practice Address - Street 2:
Practice Address - City:SUCCASUNNA
Practice Address - State:NJ
Practice Address - Zip Code:07876-1311
Practice Address - Country:US
Practice Address - Phone:973-584-8447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ188851223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics