Provider Demographics
NPI:1619357175
Name:KHAN, AYESHAW JABEEN (DMD)
Entity type:Individual
Prefix:DR
First Name:AYESHAW
Middle Name:JABEEN
Last Name:KHAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-2442
Mailing Address - Country:US
Mailing Address - Phone:623-327-3206
Mailing Address - Fax:623-327-0563
Practice Address - Street 1:407 N 4TH ST
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-2442
Practice Address - Country:US
Practice Address - Phone:623-327-3206
Practice Address - Fax:623-327-0563
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-31
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009227122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ044247Medicaid