Provider Demographics
NPI:1326727439
Name:DAIFALLAH, KHALED OMAR (DDS)
Entity Type:Individual
Prefix:DR
First Name:KHALED
Middle Name:OMAR
Last Name:DAIFALLAH
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 1:430 BUCKINGHAM RD APT 1721
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-5765
Mailing Address - Country:US
Mailing Address - Phone:952-215-5287
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:952-215-5287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX397641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice