Provider Demographics
NPI:1356808885
Name:KHALLAF, MUSTAFA (DDS)
Entity type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:
Last Name:KHALLAF
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 1:11201 SHAKER BLVD STE 136
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-3833
Mailing Address - Country:US
Mailing Address - Phone:216-368-7238
Mailing Address - Fax:216-721-8171
Practice Address - Street 1:11201 SHAKER BLVD STE 136
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3833
Practice Address - Country:US
Practice Address - Phone:216-368-7238
Practice Address - Fax:216-721-8171
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.0039921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice