Provider Demographics
NPI:1972941201
Name:KHOBAHY, IDA (DDS)
Entity type:Individual
Prefix:DR
First Name:IDA
Middle Name:
Last Name:KHOBAHY
Suffix:
Gender:F
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:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-0568
Mailing Address - Country:US
Mailing Address - Phone:503-352-8657
Mailing Address - Fax:503-352-8658
Practice Address - Street 1:44 N 11TH AVE
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:OR
Practice Address - Zip Code:97113-9020
Practice Address - Country:US
Practice Address - Phone:503-359-8505
Practice Address - Fax:503-359-8535
Is Sole Proprietor?:No
Enumeration Date:2013-06-09
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10260122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist