Healthcare Provider Details

I. General information

NPI: 1730882457
Provider Name (Legal Business Name): RIDILA KHAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RIDILA RABBI

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7525 N CEDAR AVE STE 105
FRESNO CA
93720-2698
US

IV. Provider business mailing address

21 W BARCELONA LN
CLOVIS CA
93619-2601
US

V. Phone/Fax

Practice location:
  • Phone: 559-439-6600
  • Fax:
Mailing address:
  • Phone: 559-708-2587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901601601
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number111144
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: