Provider Demographics
NPI:1437774163
Name:KHULLAR, ISHA WATTS
Entity Type:Individual
Prefix:
First Name:ISHA
Middle Name:WATTS
Last Name:KHULLAR
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 1:4786 W COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-2878
Mailing Address - Country:US
Mailing Address - Phone:754-304-6468
Mailing Address - Fax:
Practice Address - Street 1:7401 N UNIVERSITY DR STE 207
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2934
Practice Address - Country:US
Practice Address - Phone:954-721-6950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN27243122300000X
OHRES0048201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice