Provider Demographics
NPI:1922258789
Name:KHAN, ETASAM ALI (DDS)
Entity Type:Individual
Prefix:DR
First Name:ETASAM
Middle Name:ALI
Last Name:KHAN
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 1:2975 KINGSLEY DR STE 127
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-4213
Mailing Address - Country:US
Mailing Address - Phone:281-506-7987
Mailing Address - Fax:832-230-3744
Practice Address - Street 1:2975 KINGSLEY DR STE 127
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-4213
Practice Address - Country:US
Practice Address - Phone:281-506-7987
Practice Address - Fax:832-230-3744
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000089201223G0001X
TX258431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice