Provider Demographics
NPI:1598505083
Name:KHODADOUSTAN, KHASHAYAR (DDS)
Entity type:Individual
Prefix:DR
First Name:KHASHAYAR
Middle Name:
Last Name:KHODADOUSTAN
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 1:1738 PALISADE CIR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1721
Mailing Address - Country:US
Mailing Address - Phone:651-757-0940
Mailing Address - Fax:
Practice Address - Street 1:1126 IVES AVE N
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-2226
Practice Address - Country:US
Practice Address - Phone:320-864-3215
Practice Address - Fax:320-864-2768
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND150731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice