Provider Demographics
NPI:1386012946
Name:KHALILI, CHANTAL
Entity Type:Individual
Prefix:
First Name:CHANTAL
Middle Name:
Last Name:KHALILI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S DOHENY DR APT 709
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-2992
Mailing Address - Country:US
Mailing Address - Phone:310-498-3498
Mailing Address - Fax:
Practice Address - Street 1:2233 E GARVEY AVE N
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-1500
Practice Address - Country:US
Practice Address - Phone:626-966-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA650651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice