Provider Demographics
NPI:1336368141
Name:KHALILI, FEREYDOUN I (DDS)
Entity Type:Individual
Prefix:DR
First Name:FEREYDOUN
Middle Name:
Last Name:KHALILI
Suffix:I
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 1:103-43 LEFFERTS BLVD.
Mailing Address - Street 2:2ND FL.
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419
Mailing Address - Country:US
Mailing Address - Phone:718-843-5500
Mailing Address - Fax:718-841-7600
Practice Address - Street 1:103-43 LEFFERTS BLVD.
Practice Address - Street 2:2ND FL.
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419
Practice Address - Country:US
Practice Address - Phone:718-843-5500
Practice Address - Fax:718-841-7600
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0461061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01644504Medicaid