Healthcare Provider Details

I. General information

NPI: 1891575700
Provider Name (Legal Business Name): SHAKEEL ANWAR KHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2023
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12242 K PLZ STE 113
OMAHA NE
68137-2259
US

IV. Provider business mailing address

260 S 208TH ST
ELKHORN NE
68022-1810
US

V. Phone/Fax

Practice location:
  • Phone: 402-334-8083
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN28570
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number7982
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: