Provider Demographics
NPI:1417173683
Name:KALANTAROV, KHAIM
Entity Type:Individual
Prefix:
First Name:KHAIM
Middle Name:
Last Name:KALANTAROV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1096 ALPHARETTA ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075
Mailing Address - Country:US
Mailing Address - Phone:770-993-9048
Mailing Address - Fax:
Practice Address - Street 1:1096 ALPHARETTA ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075
Practice Address - Country:US
Practice Address - Phone:770-993-9048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012445122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist