Provider Demographics
NPI:1174666796
Name:KHALIL, VICTOR
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:
Last Name:KHALIL
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:PO BOX 4461
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-9597
Mailing Address - Country:US
Mailing Address - Phone:310-849-0215
Mailing Address - Fax:
Practice Address - Street 1:19005 WILEYS WELL RD
Practice Address - Street 2:
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-2287
Practice Address - Country:US
Practice Address - Phone:760-921-7548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47107122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD47107Medicaid