Provider Demographics
NPI:1164424016
Name:KHAN, MAHAMID ALI (DMD)
Entity Type:Individual
Prefix:MR
First Name:MAHAMID
Middle Name:ALI
Last Name:KHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4511
Mailing Address - Country:US
Mailing Address - Phone:773-254-1400
Mailing Address - Fax:312-829-6375
Practice Address - Street 1:6447 CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2311
Practice Address - Country:US
Practice Address - Phone:773-254-1400
Practice Address - Fax:312-829-6375
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005002250122300000X
IL019024670122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019024670Medicaid
MO407262500Medicaid