Healthcare Provider Details

I. General information

NPI: 1497295679
Provider Name (Legal Business Name): SKK DENTAL PLLC DBA LIBERTY DENTAL ARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 06/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2749 W RIDGE RD
ROCHESTER NY
14626-3038
US

IV. Provider business mailing address

2749 W RIDGE RD
ROCHESTER NY
14626-3038
US

V. Phone/Fax

Practice location:
  • Phone: 585-343-2090
  • Fax:
Mailing address:
  • Phone: 585-343-2090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number042165
License Number StateNY

VIII. Authorized Official

Name: DR. SAMIR K KHALIL
Title or Position: DENTIST
Credential: DDS
Phone: 585-434-2090