Provider Demographics
NPI:1730556358
Name:KHATTARI, MOHAMMED (DDS)
Entity type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:
Last Name:KHATTARI
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 1:7777 N WICKHAM RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7976
Mailing Address - Country:US
Mailing Address - Phone:321-255-6303
Mailing Address - Fax:321-255-6710
Practice Address - Street 1:7777 N WICKHAM RD
Practice Address - Street 2:SUITE 4
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7976
Practice Address - Country:US
Practice Address - Phone:321-255-6303
Practice Address - Fax:321-255-6710
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 21580122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist