MEDICARE: DR. ALEKSANDER KHASIDOV D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DS041975	PA

General Provider Information

NPI Number	:	1770014011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALEKSANDER KHASIDOV D.D.S

Provider Business Mailing Address
First Line	:	11150 76TH RD
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-6454
Country	:	US
Telephone Number	:	917-349-3272
Fax Number	:

Provider Business Practice Location Address
First Line	:	1575 BLONDELL AVE STE 150
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-2661
Country	:	US
Telephone Number	:	888-700-6623
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2017
Last Update Date	:	10/02/2018

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