Provider Demographics
NPI:1649636499
Name:KHALIL, MARIAN
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:KHALIL
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 1:2679 SAINT JOSEPH DR E APT A
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-1722
Mailing Address - Country:US
Mailing Address - Phone:248-269-3346
Mailing Address - Fax:
Practice Address - Street 1:1044 BELMONT AVE.
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44501-1790
Practice Address - Country:US
Practice Address - Phone:330-480-3195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-10
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
FLDN232071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program