Healthcare Provider Details

I. General information

NPI: 1285314815
Provider Name (Legal Business Name): SHAHMIR AKBAR KHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 W TWINCOURT TRL
ST AUGUSTINE FL
32095-8881
US

IV. Provider business mailing address

W249N5245 EXECUTIVE DR STE 206
SUSSEX WI
53089-4393
US

V. Phone/Fax

Practice location:
  • Phone: 904-901-4684
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6001272
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN30021
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: