Provider Demographics
NPI:1588672430
Name:AL-KHADRA, ENAS (DDS)
Entity Type:Individual
Prefix:
First Name:ENAS
Middle Name:
Last Name:AL-KHADRA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 NE 20TH TER STE 301
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4510
Mailing Address - Country:US
Mailing Address - Phone:954-727-9865
Mailing Address - Fax:954-727-9940
Practice Address - Street 1:4800 NE 20TH TER STE 301
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4510
Practice Address - Country:US
Practice Address - Phone:954-727-9865
Practice Address - Fax:954-727-9940
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN166501223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075773000Medicaid