Provider Demographics
NPI:1700496023
Name:KHAN, ALTAZ (DDS)
Entity Type:Individual
Prefix:
First Name:ALTAZ
Middle Name:
Last Name:KHAN
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 1:8612 107TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1604
Mailing Address - Country:US
Mailing Address - Phone:646-322-0826
Mailing Address - Fax:
Practice Address - Street 1:1545 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1122
Practice Address - Country:US
Practice Address - Phone:718-413-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-01
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062033122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist