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General NPI Number Information
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NPI Number | 1336700046
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Entity Type | Individual
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Provider Name | MUSTAJAB KHALIL DMD
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Gender | Male
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Dates
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Enumeration Date | 06/24/2019
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Last Update Date | 06/24/2019
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Provider Practice Location Address
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Address Line | 1450 CLEMENTS BRIDGE RD STE 13
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City | DEPTFORD
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State | NJ
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Zip | 08096-3068
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Country | US
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Telephone | 856-322-0536
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Fax |
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Provider Business Mailing Address
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Address Line | 121 S 43RD ST APT 402
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City | PHILADELPHIA
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State | PA
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Zip | 19104-3195
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Country | US
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Telephone | 267-602-7211
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DS042225
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License Number State | PA
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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 | 22DI02761100
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License Number State | NJ
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