Provider Demographics
NPI:1629649355
Name:KHALIQ, SHAMAILA
Entity Type:Individual
Prefix:
First Name:SHAMAILA
Middle Name:
Last Name:KHALIQ
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 1:1622 HOLLAND RD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-6767
Mailing Address - Country:US
Mailing Address - Phone:757-539-2998
Mailing Address - Fax:
Practice Address - Street 1:1622 HOLLAND RD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-6767
Practice Address - Country:US
Practice Address - Phone:757-539-2998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-04
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN122399122300000X
VA04014178071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist