Provider Demographics
NPI:1093495079
Name:KHAN, MOHAMMAD HASEEB (DDS)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:HASEEB
Last Name:KHAN
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 LORD ST UNIT 328
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-3330
Mailing Address - Country:US
Mailing Address - Phone:786-531-2233
Mailing Address - Fax:
Practice Address - Street 1:5706 BENJAMIN CENTER DR STE 103
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5262
Practice Address - Country:US
Practice Address - Phone:813-288-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001245122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty