Provider Demographics
NPI:1336593110
Name:KHALAJ, MONA
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:
Last Name:KHALAJ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 WILLIAMSON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-7611
Mailing Address - Country:US
Mailing Address - Phone:867-360-8670
Mailing Address - Fax:
Practice Address - Street 1:1209 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3511
Practice Address - Country:US
Practice Address - Phone:980-223-2607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11145122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist