Provider Demographics
NPI:1689116113
Name:SAN, KHIN MIMI (BCHD)
Entity Type:Individual
Prefix:MS
First Name:KHIN MIMI
Middle Name:
Last Name:SAN
Suffix:
Gender:F
Credentials:BCHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 VIKING DRIVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:VA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7354
Mailing Address - Country:US
Mailing Address - Phone:757-486-8181
Mailing Address - Fax:757-463-0148
Practice Address - Street 1:477 VIKING DRIVE
Practice Address - Street 2:SUITE 190
Practice Address - City:VA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7354
Practice Address - Country:US
Practice Address - Phone:757-486-8181
Practice Address - Fax:757-463-0148
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014166901223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics