Provider Demographics
NPI:1295840304
Name:ABUGHAZALEH, KHALED (BDS,DMD)
Entity Type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:ABUGHAZALEH
Suffix:
Gender:M
Credentials:BDS,DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 E SCOTT ST APT 9A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-5274
Mailing Address - Country:US
Mailing Address - Phone:312-498-1588
Mailing Address - Fax:
Practice Address - Street 1:65 E SCOTT ST APT 9A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-5274
Practice Address - Country:US
Practice Address - Phone:312-498-1588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery