Provider Demographics
NPI:1144722794
Name:KHAN, ABDUL JABBAR (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:ABDUL
Middle Name:JABBAR
Last Name:KHAN
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2243 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-4216
Mailing Address - Country:US
Mailing Address - Phone:470-272-4607
Mailing Address - Fax:
Practice Address - Street 1:50 JUDSON ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-7023
Practice Address - Country:US
Practice Address - Phone:470-272-4607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-28
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180071481223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice