Provider Demographics
NPI:1710468228
Name:KHAZALI, ETHAN S (DMD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:S
Last Name:KHAZALI
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 1:2576 152ND AVE NE APT B502
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-0716
Mailing Address - Country:US
Mailing Address - Phone:615-480-4279
Mailing Address - Fax:
Practice Address - Street 1:932 ALLEN RD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37214-3507
Practice Address - Country:US
Practice Address - Phone:615-781-9335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE608626831223G0001X
TN114431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice