Provider Demographics
NPI:1912073792
Name:TIAGHA, KHELLI A (DMD)
Entity Type:Individual
Prefix:DR
First Name:KHELLI
Middle Name:A
Last Name:TIAGHA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1736 DICKERSON BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-2832
Mailing Address - Country:US
Mailing Address - Phone:704-225-8555
Mailing Address - Fax:704-225-8556
Practice Address - Street 1:1736 DICKERSON BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-2832
Practice Address - Country:US
Practice Address - Phone:704-225-8555
Practice Address - Fax:704-225-8556
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC75511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice