Healthcare Provider Details

I. General information

NPI: 1003349770
Provider Name (Legal Business Name): JOSEPH KHALOO D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2017
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11215 84TH AVE
RICHMOND HILL NY
11418-1321
US

IV. Provider business mailing address

11215 84TH AVE
RICHMOND HILL NY
11418-1321
US

V. Phone/Fax

Practice location:
  • Phone: 347-556-1994
  • Fax:
Mailing address:
  • Phone: 347-556-1994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number060118
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: