Healthcare Provider Details

I. General information

NPI: 1306176052
Provider Name (Legal Business Name): MAGED KHEDR D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2009
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WALNUT STREET I-DENTICAL
PHILADELPHIA PA
19106
US

IV. Provider business mailing address

2323 RACE ST UNIT 807
PHILADELPHIA PA
19103-1082
US

V. Phone/Fax

Practice location:
  • Phone: 215-923-3233
  • Fax:
Mailing address:
  • Phone: 954-288-0589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS037706
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: