Provider Demographics
NPI:1104157932
Name:KHIBLIL, ALI MOHAMAD (BDS)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:MOHAMAD
Last Name:KHIBLIL
Suffix:
Gender:M
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 WASHINGTON ST
Mailing Address - Street 2:APTT # 11
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-8200
Mailing Address - Country:US
Mailing Address - Phone:781-475-3646
Mailing Address - Fax:
Practice Address - Street 1:100 E NEWTON ST
Practice Address - Street 2:7TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2308
Practice Address - Country:US
Practice Address - Phone:617-638-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-18
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL108511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice