Provider Demographics
NPI:1699452649
Name:GONI-MALLOUMI, KHADIDJA
Entity type:Individual
Prefix:
First Name:KHADIDJA
Middle Name:
Last Name:GONI-MALLOUMI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8950 BRADWELL PL APT 205
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-8619
Mailing Address - Country:US
Mailing Address - Phone:202-853-4838
Mailing Address - Fax:
Practice Address - Street 1:1547 OHIO AVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-1917
Practice Address - Country:US
Practice Address - Phone:765-641-7499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014097A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist