Healthcare Provider Details

I. General information

NPI: 1043309941
Provider Name (Legal Business Name): CHARLES KHOURY, DMD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 HUTTLESTON AVE 1ST FLOOR
FAIRHAVEN MA
02719
US

IV. Provider business mailing address

1428 DARTMOUTH WOODS DRIVE
DARTMOUTH MA
02747
US

V. Phone/Fax

Practice location:
  • Phone: 508-997-7776
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number20015
License Number StateMA

VIII. Authorized Official

Name: DR. CHARLES KHOURY
Title or Position: PRESIDENT
Credential: DMD
Phone: 508-997-7776