Provider Demographics
NPI:1992976427
Name:KHADER, RUBA NAIM (BDS)
Entity type:Individual
Prefix:
First Name:RUBA
Middle Name:NAIM
Last Name:KHADER
Suffix:
Gender:F
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 W FLORIDA ST STE 105
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-1509
Mailing Address - Country:US
Mailing Address - Phone:414-810-1707
Mailing Address - Fax:
Practice Address - Street 1:408 W FLORIDA ST STE 105
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-1509
Practice Address - Country:US
Practice Address - Phone:414-810-1707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9594122300000X
KY90021223S0112X, 204E00000X
WI10009601223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1992976427Medicaid