Provider Demographics
NPI:1902263916
Name:RAMI A KHOURY DMD PC
Entity Type:Organization
Organization Name:RAMI A KHOURY DMD PC
Other - Org Name:BROADWAY FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMI
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-691-3311
Mailing Address - Street 1:1003 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015
Mailing Address - Country:US
Mailing Address - Phone:610-691-3311
Mailing Address - Fax:610-317-6052
Practice Address - Street 1:1003 BROADWAY
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-4101
Practice Address - Country:US
Practice Address - Phone:610-691-3311
Practice Address - Fax:610-317-6052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035891122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101874749 0001Medicaid
1215069752OtherINDIVIDUAL NPI