Provider Demographics
NPI:1659159168
Name:KHAN, USMAN KHURRAM
Entity type:Individual
Prefix:
First Name:USMAN
Middle Name:KHURRAM
Last Name:KHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 DUCKHORN DR APT 2132
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1372
Mailing Address - Country:US
Mailing Address - Phone:415-990-6533
Mailing Address - Fax:
Practice Address - Street 1:2041 BRONZE STAR DR STE 100
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95776-5428
Practice Address - Country:US
Practice Address - Phone:530-662-7592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2024-07-11
Deactivation Date:2024-06-26
Deactivation Code:
Reactivation Date:2024-07-09
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA110207122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program