Healthcare Provider Details

I. General information

NPI: 1093773632
Provider Name (Legal Business Name): GHAZALA RAHMAN KHAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 SUN HAVEN PL SUITE 1
MANTECA CA
95337-4316
US

IV. Provider business mailing address

411 FUCHSIA LN
SAN RAMON CA
94582-5710
US

V. Phone/Fax

Practice location:
  • Phone: 925-819-1996
  • Fax:
Mailing address:
  • Phone: 925-736-8659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number51483
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: