Healthcare Provider Details

I. General information

NPI: 1154463974
Provider Name (Legal Business Name): VAJAHAT YAR KHAN BDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 NE 28TH ST
FORT WORTH TX
76164-7205
US

IV. Provider business mailing address

6103 W MASTERS DR APT # 1214
FORT WORTH TX
76137-6865
US

V. Phone/Fax

Practice location:
  • Phone: 817-624-0044
  • Fax: 817-624-0041
Mailing address:
  • Phone: 713-992-2114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number23077
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: