Provider Demographics
NPI:1427217694
Name:KHANNA, SHACHIKA (DMD)
Entity Type:Individual
Prefix:
First Name:SHACHIKA
Middle Name:
Last Name:KHANNA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 WALNUT STREET
Mailing Address - Street 2:300 COB
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5211
Mailing Address - Country:US
Mailing Address - Phone:215-955-6215
Mailing Address - Fax:215-923-9189
Practice Address - Street 1:909 WALNUT STREET
Practice Address - Street 2:300 COB
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5211
Practice Address - Country:US
Practice Address - Phone:215-955-6215
Practice Address - Fax:215-923-9189
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0390591223S0112X, 204E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program