Healthcare Provider Details

I. General information

NPI: 1477614162
Provider Name (Legal Business Name): MARK I KHAIMOV DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 CENTRE ST
NUTLEY NJ
07110-2828
US

IV. Provider business mailing address

180 CENTRE ST
NUTLEY NJ
07110-2828
US

V. Phone/Fax

Practice location:
  • Phone: 973-798-2639
  • Fax: 973-798-2640
Mailing address:
  • Phone: 973-798-2639
  • Fax: 973-798-2640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2249201
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: