Provider Demographics
NPI:1952467334
Name:KHAN, WALI (DDS)
Entity Type:Individual
Prefix:
First Name:WALI
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 1:3733 77TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6629
Mailing Address - Country:US
Mailing Address - Phone:718-478-6100
Mailing Address - Fax:718-476-9454
Practice Address - Street 1:1221 WHITE PLAINS RD
Practice Address - Street 2:SUITE 106
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-4937
Practice Address - Country:US
Practice Address - Phone:718-792-6991
Practice Address - Fax:718-792-0654
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0450031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01471549Medicaid