Provider Demographics
NPI:1396575635
Name:KHELLA, MARIAM (DDS)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:KHELLA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:948 CONEFLOWER CT
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55123-3978
Mailing Address - Country:US
Mailing Address - Phone:651-447-9835
Mailing Address - Fax:
Practice Address - Street 1:9042 CAHILL AVE
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55076-3543
Practice Address - Country:US
Practice Address - Phone:651-457-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND151741223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice