Provider Demographics
NPI:1770014011
Name:KHASIDOV, ALEKSANDER (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALEKSANDER
Middle Name:
Last Name:KHASIDOV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11150 76TH RD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-6454
Mailing Address - Country:US
Mailing Address - Phone:917-349-3272
Mailing Address - Fax:
Practice Address - Street 1:1575 BLONDELL AVE STE 150
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2661
Practice Address - Country:US
Practice Address - Phone:888-700-6623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0419751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice