Provider Demographics
NPI:1780420059
Name:KHUSRO, KHANSA (DDS)
Entity type:Individual
Prefix:
First Name:KHANSA
Middle Name:
Last Name:KHUSRO
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 1:1927 CLARKIA ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-0213
Mailing Address - Country:US
Mailing Address - Phone:805-667-7751
Mailing Address - Fax:
Practice Address - Street 1:23130 LYONS AVE
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2631
Practice Address - Country:US
Practice Address - Phone:661-219-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-05
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016022971223G0001X
CADDS1110201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice