Provider Demographics
NPI:1538629498
Name:KHAN, MABROOR A (DMD)
Entity type:Individual
Prefix:
First Name:MABROOR
Middle Name:A
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 1:115 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3603
Mailing Address - Country:US
Mailing Address - Phone:860-446-8744
Mailing Address - Fax:
Practice Address - Street 1:115 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3603
Practice Address - Country:US
Practice Address - Phone:860-446-8744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042583122300000X
CT13683122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1037653870001Medicaid