Healthcare Provider Details

I. General information

NPI: 1073734612
Provider Name (Legal Business Name): ADEL S. KHALIL D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 WEBSTER ST STE 200
BERKELEY CA
94705-2050
US

IV. Provider business mailing address

2435 WEBSTER ST STE 200
BERKELEY CA
94705-2050
US

V. Phone/Fax

Practice location:
  • Phone: 510-548-9114
  • Fax: 510-548-8046
Mailing address:
  • Phone: 510-548-9114
  • Fax: 510-548-8046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number59216
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901018891
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number4301093272
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901018891
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: