Provider Demographics
NPI:1285186932
Name:IRFAN AZIZ KHAN INC
Entity Type:Organization
Organization Name:IRFAN AZIZ KHAN INC
Other - Org Name:GRANDVIEW YARD POLARIS DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREATMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWERSOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-505-7027
Mailing Address - Street 1:885 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-3106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:885 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3106
Practice Address - Country:US
Practice Address - Phone:614-505-7027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.022887122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty