Provider Demographics
NPI:1336346196
Name:KHAN, MIR MA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIR
Middle Name:MA
Last Name:KHAN
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:620 COUNTRY CLUB APTS
Mailing Address - Street 2:ROUTE 309 N
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-8925
Mailing Address - Country:US
Mailing Address - Phone:215-431-2000
Mailing Address - Fax:
Practice Address - Street 1:1111 E END BLVD
Practice Address - Street 2:VAMC MEDICAL CENTER DENTAL SERVICE
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0030
Practice Address - Country:US
Practice Address - Phone:570-824-3521
Practice Address - Fax:570-819-5153
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY052574-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist