Healthcare Provider Details

I. General information

NPI: 1144419433
Provider Name (Legal Business Name): MOHAMMAD A KHEIRALLA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 SUNSET STRIP
SUCCASUNNA NJ
07876-1311
US

IV. Provider business mailing address

73 SUNSET STRIP
SUCCASUNNA NJ
07876-1311
US

V. Phone/Fax

Practice location:
  • Phone: 973-584-8447
  • Fax:
Mailing address:
  • Phone: 973-584-8447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number18885
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: