Healthcare Provider Details

I. General information

NPI: 1518729938
Provider Name (Legal Business Name): BUSHRA TAHIR KHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2024
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

355 WATFORD DR APT A
BALLWIN MO
63011-3784
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2026024258
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: