Provider Demographics
NPI:1578175089
Name:KHAVIS, RAFAEL (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:
Last Name:KHAVIS
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 AMHERST MANOR DR APT 109
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2030
Mailing Address - Country:US
Mailing Address - Phone:917-822-4185
Mailing Address - Fax:
Practice Address - Street 1:DENT TOWER SUITE 401
Practice Address - Street 2:3980 SHERIDAN DRIVE
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226
Practice Address - Country:US
Practice Address - Phone:917-822-4185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0610881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice