Provider Demographics
NPI:1538177340
Name:KHALIL, MAMOUN K (DDS)
Entity type:Individual
Prefix:MR
First Name:MAMOUN
Middle Name:K
Last Name:KHALIL
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 1:459 S CAPITAL AVE
Mailing Address - Street 2:STE # 10
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95107
Mailing Address - Country:US
Mailing Address - Phone:408-923-4989
Mailing Address - Fax:408-923-3481
Practice Address - Street 1:459 S CAPITAL AVE
Practice Address - Street 2:STE # 10
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95107
Practice Address - Country:US
Practice Address - Phone:408-923-4989
Practice Address - Fax:408-923-3481
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43801122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4380101OtherMEDI CAL CA STATE PROGRAM