Provider Demographics
NPI:1841250586
Name:KHANIJOU, PRADEEP K (DDS)
Entity type:Individual
Prefix:DR
First Name:PRADEEP
Middle Name:K
Last Name:KHANIJOU
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 1:31A VALLEY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3917
Mailing Address - Country:US
Mailing Address - Phone:516-466-2057
Mailing Address - Fax:516-466-2057
Practice Address - Street 1:120 GRANT AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-1804
Practice Address - Country:US
Practice Address - Phone:718-827-6565
Practice Address - Fax:718-827-5913
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0334921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00582370Medicaid