Provider Demographics
NPI:1851768857
Name:PRADHAN, KHAIRUNISSA MEHDI (DDS)
Entity Type:Individual
Prefix:DR
First Name:KHAIRUNISSA
Middle Name:MEHDI
Last Name:PRADHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1632 SPENCER HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77587-3752
Mailing Address - Country:US
Mailing Address - Phone:713-910-1002
Mailing Address - Fax:
Practice Address - Street 1:1632 SPENCER HWY
Practice Address - Street 2:
Practice Address - City:SOUTH HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77587-3752
Practice Address - Country:US
Practice Address - Phone:713-910-1002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2016-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31388122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist