Healthcare Provider Details

I. General information

NPI: 1255900437
Provider Name (Legal Business Name): MAHA KHADEN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 06/22/2021
Certification Date: 06/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9327 SKOKIE BLVD UNIT C
SKOKIE IL
60077-1310
US

IV. Provider business mailing address

2400 ARCHBURY LN APT 1C
PARK RIDGE IL
60068-3672
US

V. Phone/Fax

Practice location:
  • Phone: 847-227-8277
  • Fax:
Mailing address:
  • Phone: 847-877-0293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.033161
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.033161
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: