Provider Demographics
NPI:1386252781
Name:KHAN, MADIHA FAYYAZ (DDS)
Entity type:Individual
Prefix:
First Name:MADIHA
Middle Name:FAYYAZ
Last Name:KHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18115 LAKEVIEW DR APT 202
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5670
Mailing Address - Country:US
Mailing Address - Phone:570-877-0386
Mailing Address - Fax:
Practice Address - Street 1:220 E PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3532
Practice Address - Country:US
Practice Address - Phone:414-435-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002359-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist