Healthcare Provider Details

I. General information

NPI: 1033819248
Provider Name (Legal Business Name): SANABIL MANZOOR KHATTAK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 PICCADILLY DR STE A
WINSTON SALEM NC
27104-3526
US

IV. Provider business mailing address

108 PICCADILLY DR STE A
WINSTON SALEM NC
27104-3526
US

V. Phone/Fax

Practice location:
  • Phone: 336-760-8700
  • Fax: 336-518-0415
Mailing address:
  • Phone: 336-760-8700
  • Fax: 336-518-0415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN123112
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13949
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: