Provider Demographics
NPI:1538275292
Name:AHMADI, AHMAD KHALIL (DMD)
Entity type:Individual
Prefix:DR
First Name:AHMAD
Middle Name:KHALIL
Last Name:AHMADI
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 1:12311 TAFT ST
Mailing Address - Street 2:STE. # 2
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-4384
Mailing Address - Country:US
Mailing Address - Phone:954-430-5700
Mailing Address - Fax:954-430-5606
Practice Address - Street 1:12311 TAFT ST
Practice Address - Street 2:STE. # 2
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-4384
Practice Address - Country:US
Practice Address - Phone:954-430-5700
Practice Address - Fax:954-430-5606
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 162611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000036400Medicaid