Provider Demographics
NPI:1447780267
Name:KHUDIR, NAGAM
Entity Type:Individual
Prefix:
First Name:NAGAM
Middle Name:
Last Name:KHUDIR
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 1:275 S BRYN MAWR AVE APT K4
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-4240
Mailing Address - Country:US
Mailing Address - Phone:484-557-7742
Mailing Address - Fax:
Practice Address - Street 1:275 S BRYN MAWR AVE APT K4
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:WA
Practice Address - Zip Code:19010-1901
Practice Address - Country:US
Practice Address - Phone:484-557-7742
Practice Address - Fax:484-557-7742
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0413551223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice