Provider Demographics
NPI:1750754818
Name:MUTAWALLI, KHALID HASSAN (DDS,MS)
Entity type:Individual
Prefix:DR
First Name:KHALID
Middle Name:HASSAN
Last Name:MUTAWALLI
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SE 8TH AVE
Mailing Address - Street 2:APT#1640
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3644
Mailing Address - Country:US
Mailing Address - Phone:202-560-3320
Mailing Address - Fax:
Practice Address - Street 1:3625 COLLEGE AVE
Practice Address - Street 2:BX1822
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-7724
Practice Address - Country:US
Practice Address - Phone:202-560-3320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2016-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 209081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry