Provider Demographics
NPI:1205902251
Name:KHASRU, MOHAMMED AMIR (DDS)
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:AMIR
Last Name:KHASRU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S WATERMAN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3746
Mailing Address - Country:US
Mailing Address - Phone:909-433-0029
Mailing Address - Fax:909-433-0059
Practice Address - Street 1:2160 S WATERMAN AVE STE A
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3746
Practice Address - Country:US
Practice Address - Phone:909-433-0029
Practice Address - Fax:909-433-0059
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48479122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist