Provider Demographics
NPI:1982109708
Name:HABASH, KHADER SAMIR
Entity Type:Individual
Prefix:
First Name:KHADER
Middle Name:SAMIR
Last Name:HABASH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 S LIMESTONE ROOM A262
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0001
Mailing Address - Country:US
Mailing Address - Phone:859-323-6723
Mailing Address - Fax:859-323-2036
Practice Address - Street 1:740 S LIMESTONE ROOM A262
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536
Practice Address - Country:US
Practice Address - Phone:859-323-6723
Practice Address - Fax:859-323-2036
Is Sole Proprietor?:No
Enumeration Date:2018-03-25
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY390200000X
KY10099122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program