Provider Demographics
NPI:1598965899
Name:IMROZ, KHALEDA
Entity Type:Individual
Prefix:
First Name:KHALEDA
Middle Name:
Last Name:IMROZ
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 1:415 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3111
Mailing Address - Country:US
Mailing Address - Phone:719-562-4461
Mailing Address - Fax:
Practice Address - Street 1:3439 MCGEHEE RD
Practice Address - Street 2:SUITE B
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-3392
Practice Address - Country:US
Practice Address - Phone:334-288-1868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL55411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice