Provider Demographics
NPI:1629765789
Name:ELKHATIB, NOURHAN
Entity Type:Individual
Prefix:
First Name:NOURHAN
Middle Name:
Last Name:ELKHATIB
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 1:721 NORWICH RD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06374-1734
Mailing Address - Country:US
Mailing Address - Phone:857-354-9202
Mailing Address - Fax:
Practice Address - Street 1:721 NORWICH RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:CT
Practice Address - Zip Code:06374-1734
Practice Address - Country:US
Practice Address - Phone:860-546-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13814122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program