Healthcare Provider Details

I. General information

NPI: 1962132977
Provider Name (Legal Business Name): MUHAMMAD KHONDOKER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 02/09/2025
Certification Date: 02/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19911 ZION AVE STE D4
CORNELIUS NC
28031-8877
US

IV. Provider business mailing address

19911 ZION AVE STE D4
CORNELIUS NC
28031-8877
US

V. Phone/Fax

Practice location:
  • Phone: 704-887-2744
  • Fax: 929-600-9712
Mailing address:
  • Phone: 704-887-2744
  • Fax: 929-600-9712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number10332
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13419
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: