Healthcare Provider Details

I. General information

NPI: 1629593793
Provider Name (Legal Business Name): MOID KHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 DEL PASO RD STE 300
SACRAMENTO CA
95834-9717
US

IV. Provider business mailing address

PO BOX 622
WEST SACRAMENTO CA
95691-0622
US

V. Phone/Fax

Practice location:
  • Phone: 916-619-7172
  • Fax:
Mailing address:
  • Phone: 916-505-0810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number101812
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: