Provider Demographics
NPI:1679041024
Name:TAHA, KHALED (DMD)
Entity Type:Individual
Prefix:DR
First Name:KHALED
Middle Name:
Last Name:TAHA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 DELTA RD APT 2
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1122
Mailing Address - Country:US
Mailing Address - Phone:202-725-2160
Mailing Address - Fax:
Practice Address - Street 1:4072 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701-2820
Practice Address - Country:US
Practice Address - Phone:757-337-4261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-04
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014164091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics