Provider Demographics
NPI:1780021808
Name:MJAHED, KHALIL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KHALIL
Middle Name:
Last Name:MJAHED
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 1:1307 E FRANKLIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-5196
Mailing Address - Country:US
Mailing Address - Phone:704-776-4278
Mailing Address - Fax:704-776-4279
Practice Address - Street 1:1307 E FRANKLIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5196
Practice Address - Country:US
Practice Address - Phone:704-776-4278
Practice Address - Fax:704-776-4279
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC813080049Medicaid