=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730882457
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RIDILA KHAN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2023
-----------------------------------------------------
Last Update Date | 05/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7525 N CEDAR AVE STE 105
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93720-2698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-439-6600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 W BARCELONA LN
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93619-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-708-2587
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901601601
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 111144
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------