Provider Demographics
NPI:1013270594
Name:KHATTAB, SAMER K (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMER
Middle Name:K
Last Name:KHATTAB
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 1:9010 LORTON STATION BLVD
Mailing Address - Street 2:135
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-4792
Mailing Address - Country:US
Mailing Address - Phone:210-430-2740
Mailing Address - Fax:
Practice Address - Street 1:9010 LORTON STATION BLVD
Practice Address - Street 2:135
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-4792
Practice Address - Country:US
Practice Address - Phone:210-430-2740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2016-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413570122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist