Healthcare Provider Details

I. General information

NPI: 1326958307
Provider Name (Legal Business Name): SHAMINA KHANUM FAMILY DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

284 DEWEY ST
LUCEDALE MS
39452-6547
US

IV. Provider business mailing address

284 DEWEY ST
LUCEDALE MS
39452-6547
US

V. Phone/Fax

Practice location:
  • Phone: 732-675-0620
  • Fax:
Mailing address:
  • Phone: 732-675-0620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAMINA KHANUM
Title or Position: DENTIST
Credential: BDS
Phone: 732-675-0720