Provider Demographics
NPI:1912522095
Name:KHAN, SHAN M (DMD)
Entity type:Individual
Prefix:DR
First Name:SHAN
Middle Name:M
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 1:282 S 5TH ST APT 13C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-6602
Mailing Address - Country:US
Mailing Address - Phone:302-650-3810
Mailing Address - Fax:
Practice Address - Street 1:1302 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1970
Practice Address - Country:US
Practice Address - Phone:718-376-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-14
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061762-01122300000X
AR4424122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist