Provider Demographics
NPI:1124433396
Name:KHILLAH, SHADI RADY (DDS)
Entity type:Individual
Prefix:
First Name:SHADI
Middle Name:RADY
Last Name:KHILLAH
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 1:357 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49053-9763
Mailing Address - Country:US
Mailing Address - Phone:269-665-9997
Mailing Address - Fax:269-665-5088
Practice Address - Street 1:357 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053-9763
Practice Address - Country:US
Practice Address - Phone:269-665-9997
Practice Address - Fax:269-665-5088
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021326122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist