Provider Demographics
NPI:1235276569
Name:KHEIRI, AFAQ MOHAMMAD (DDS)
Entity Type:Individual
Prefix:DR
First Name:AFAQ
Middle Name:MOHAMMAD
Last Name:KHEIRI
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 1:1200 W MONROE ST APT 603
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2550
Mailing Address - Country:US
Mailing Address - Phone:312-243-0029
Mailing Address - Fax:
Practice Address - Street 1:2316 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2228
Practice Address - Country:US
Practice Address - Phone:312-491-0601
Practice Address - Fax:312-491-0602
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9177289Medicaid