Provider Demographics
NPI:1275825176
Name:KHAN, MANSOOR IRSHAD (BDS, AEGD,FAGD)
Entity Type:Individual
Prefix:DR
First Name:MANSOOR
Middle Name:IRSHAD
Last Name:KHAN
Suffix:
Gender:M
Credentials:BDS, AEGD,FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1573 SAXON BLVD STE 100&101
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-5833
Mailing Address - Country:US
Mailing Address - Phone:286-218-0046
Mailing Address - Fax:
Practice Address - Street 1:1573 SAXON BLVD STE 100&101
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-5833
Practice Address - Country:US
Practice Address - Phone:386-218-0046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 20334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist