Provider Demographics
NPI:1326531088
Name:KHATLAN, GAITH (DMD)
Entity Type:Individual
Prefix:
First Name:GAITH
Middle Name:
Last Name:KHATLAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:GHAITH
Other - Middle Name:
Other - Last Name:AL KHUZAIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1127 WASHINGTON BLVD APT 3I
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3660
Mailing Address - Country:US
Mailing Address - Phone:206-375-7915
Mailing Address - Fax:
Practice Address - Street 1:2241 THEODORE ST
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1881
Practice Address - Country:US
Practice Address - Phone:815-741-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031631122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist