Provider Demographics
NPI:1629497086
Name:AHGHAR, KEON J (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEON
Middle Name:J
Last Name:AHGHAR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4969
Mailing Address - Country:US
Mailing Address - Phone:575-622-4455
Mailing Address - Fax:575-624-2556
Practice Address - Street 1:824 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4969
Practice Address - Country:US
Practice Address - Phone:575-622-4455
Practice Address - Fax:575-624-2556
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD42751223G0001X, 1223S0112X, 122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01350731Medicaid