Provider Demographics
NPI:1982347332
Name:KHAN, HIRA TARIQ
Entity Type:Individual
Prefix:MISS
First Name:HIRA
Middle Name:TARIQ
Last Name:KHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HIRA
Other - Middle Name:
Other - Last Name:TARIQ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2780 DRAYTON HALL DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-5803
Mailing Address - Country:US
Mailing Address - Phone:678-515-5915
Mailing Address - Fax:
Practice Address - Street 1:890 DAWSONVILLE HWY # F
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2607
Practice Address - Country:US
Practice Address - Phone:678-928-3219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN122838122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program