Healthcare Provider Details

I. General information

NPI: 1639770266
Provider Name (Legal Business Name): FAHAD GUL KHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 BATTLEGROUND AVE
GREENSBORO NC
27408-5422
US

IV. Provider business mailing address

477 GIBBS POND RD
NESCONSET NY
11767-2108
US

V. Phone/Fax

Practice location:
  • Phone: 336-355-4554
  • Fax:
Mailing address:
  • Phone: 347-326-0440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12990
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: