Provider Demographics
NPI:1013794791
Name:KHADRA, MOHAMMAD TAREQ (DDS)
Entity type:Individual
Prefix:
First Name:MOHAMMAD TAREQ
Middle Name:
Last Name:KHADRA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:TAREQ
Other - Middle Name:
Other - Last Name:KHADRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:18530 AMBROSIO CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-3411
Mailing Address - Country:US
Mailing Address - Phone:401-225-2455
Mailing Address - Fax:
Practice Address - Street 1:2675 S ABILENE ST STE 135
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-2363
Practice Address - Country:US
Practice Address - Phone:401-225-2455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-14
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00205725122300000X
CA1092961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist