Provider Demographics
NPI:1821737180
Name:KHAN, AYESHA (DMD)
Entity Type:Individual
Prefix:DR
First Name:AYESHA
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 E 14TH ST APT 513
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2837
Mailing Address - Country:US
Mailing Address - Phone:773-750-5205
Mailing Address - Fax:
Practice Address - Street 1:6283 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2505
Practice Address - Country:US
Practice Address - Phone:708-586-9194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190336281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice