Provider Demographics
NPI:1366952897
Name:KHAN, MOHAMMAD ABBAS (DMD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:ABBAS
Last Name:KHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CORNERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-6302
Mailing Address - Country:US
Mailing Address - Phone:617-637-3637
Mailing Address - Fax:
Practice Address - Street 1:101 CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-6302
Practice Address - Country:US
Practice Address - Phone:617-637-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT121641223G0001X
MADN1857790122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice