Healthcare Provider Details

I. General information

NPI: 1336394873
Provider Name (Legal Business Name): ISLAM ABDELHADY KHASAWNEH DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12335 HYMEADOW DR STE 250
AUSTIN TX
78750-1934
US

IV. Provider business mailing address

13730 FM 620 APT 427
AUSTIN TX
78717-1034
US

V. Phone/Fax

Practice location:
  • Phone: 512-250-5012
  • Fax:
Mailing address:
  • Phone: 443-889-3147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number24287
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number24287
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: