Provider Demographics
NPI:1336700046
Name:KHALIL, MUSTAJAB (DMD)
Entity Type:Individual
Prefix:
First Name:MUSTAJAB
Middle Name:
Last Name:KHALIL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S 43RD ST APT 402
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3195
Mailing Address - Country:US
Mailing Address - Phone:267-602-7211
Mailing Address - Fax:
Practice Address - Street 1:1450 CLEMENTS BRIDGE RD STE 13
Practice Address - Street 2:
Practice Address - City:DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-3068
Practice Address - Country:US
Practice Address - Phone:856-322-0536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0422251223G0001X
NJ22DI027611001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice