Healthcare Provider Details

I. General information

NPI: 1578101630
Provider Name (Legal Business Name): MARYAM KHALILI DDS-PROSTHODONTIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 N BROAD ST OFC 314
PHILADELPHIA PA
19140-5007
US

IV. Provider business mailing address

1180 RAYMOND BLVD APT 11C
NEWARK NJ
07102-4120
US

V. Phone/Fax

Practice location:
  • Phone: 773-807-9934
  • Fax:
Mailing address:
  • Phone: 773-807-9934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number34590
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401416303
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberRFD000033
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: