Provider Demographics
NPI:1194278440
Name:KHATTAK, SHAZIA (DMD)
Entity type:Individual
Prefix:DR
First Name:SHAZIA
Middle Name:
Last Name:KHATTAK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 N PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-1911
Mailing Address - Country:US
Mailing Address - Phone:315-866-1270
Mailing Address - Fax:
Practice Address - Street 1:314 N PROSPECT ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-1911
Practice Address - Country:US
Practice Address - Phone:315-866-1270
Practice Address - Fax:315-867-5979
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist