Provider Demographics
NPI:1417045931
Name:KHALIFEH, MOHAMMAD (DDS)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:KHALIFEH
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 1:5757 WILSHIRE BLVD.,
Mailing Address - Street 2:SUITE # 5
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036
Mailing Address - Country:US
Mailing Address - Phone:323-933-3855
Mailing Address - Fax:
Practice Address - Street 1:5757 WILSHIRE BLVD.,
Practice Address - Street 2:SUITE # 5
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036
Practice Address - Country:US
Practice Address - Phone:323-933-3855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA406311223G0001X, 1223X2210X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X2210XDental ProvidersDentistOrofacial Pain
No1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
47-0910768OtherTAXPAYER IDENTIFYING NUMB