Provider Demographics
NPI:1942989280
Name:KHALIL, KEROLOS GEORGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEROLOS
Middle Name:GEORGE
Last Name:KHALIL
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 1:2180 JENNI LN
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-9592
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2288 DANIELS ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-6706
Practice Address - Country:US
Practice Address - Phone:209-456-5610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1090821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice