Healthcare Provider Details

I. General information

NPI: 1972989952
Provider Name (Legal Business Name): TASADAQ KHAN KHAKWANI D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2015
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4980 175TH PL
FRESH MEADOWS NY
11365-1624
US

IV. Provider business mailing address

20614 EMILY RD #42M
BAYSIDE NY
11360-1181
US

V. Phone/Fax

Practice location:
  • Phone: 551-655-8955
  • Fax:
Mailing address:
  • Phone: 551-655-8955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number058753
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: