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General NPI Number Information
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NPI Number | 1013794791
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Entity Type | Individual
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Provider Name | MOHAMMAD TAREQ KHADRA DDS
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Gender | Male
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Dates
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Enumeration Date | 09/14/2023
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Last Update Date | 03/06/2025
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Provider Practice Location Address
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Address Line | 2675 S ABILENE ST STE 135
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City | AURORA
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State | CO
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Zip | 80014-2363
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Country | US
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Telephone | 401-225-2455
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Fax |
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Provider Business Mailing Address
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Address Line | 18530 AMBROSIO CIR
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City | CORONA
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State | CA
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Zip | 92881-3411
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Country | US
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Telephone | 401-225-2455
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 00205725
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 109296
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License Number State | CA
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