Healthcare Provider Details

I. General information

NPI: 1730873860
Provider Name (Legal Business Name): MAHVISH FATIMA KHAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N PACIFIC COAST HWY # 100A
REDONDO BEACH CA
90277-2840
US

IV. Provider business mailing address

10181 ABLE ST NE
BLAINE MN
55434-2677
US

V. Phone/Fax

Practice location:
  • Phone: 310-469-9353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113695
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: