Provider Demographics
NPI:1669432373
Name:KHANNA, RAJ K (DMD, MD)
Entity type:Individual
Prefix:
First Name:RAJ
Middle Name:K
Last Name:KHANNA
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 2500
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3656
Mailing Address - Country:US
Mailing Address - Phone:304-691-1200
Mailing Address - Fax:304-691-1287
Practice Address - Street 1:1600 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 2500
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3656
Practice Address - Country:US
Practice Address - Phone:304-691-1200
Practice Address - Fax:304-691-1287
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35261223S0112X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2330294Medicaid
WV4002154000Medicaid
KY60001526Medicaid
WV4085402Medicare ID - Type Unspecified
KY60001526Medicaid