Provider Demographics
NPI:1245321827
Name:KHAFSAFARD, ALI R (DDS)
Entity type:Individual
Prefix:DR
First Name:ALI
Middle Name:R
Last Name:KHAFSAFARD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:ALI
Other - Middle Name:R
Other - Last Name:KHAKSAFARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1076 EAGLETON CENTER UNIT C
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140
Mailing Address - Country:US
Mailing Address - Phone:740-852-7741
Mailing Address - Fax:740-852-7783
Practice Address - Street 1:1076 EAGLETON CENTER UNIT C
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140
Practice Address - Country:US
Practice Address - Phone:740-852-7741
Practice Address - Fax:740-852-7783
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21821122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2417772Medicaid