MEDICARE: KHANLTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019023653	IL

General Provider Information

NPI Number	:	1104070648
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KHANLTD

Provider Business Mailing Address
First Line	:	105 E 20TH ST
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-4967
Country	:	US
Telephone Number	:	630-953-1900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1952 E 73RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-2902
Country	:	US
Telephone Number	:	773-947-8664
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MOHAMMED RAFI KHAN
Credential	:
Telephone Number	:	630-953-1900

Provider Enumeration Date	:	11/11/2008
Last Update Date	:	11/11/2008

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Directions to “KHANLTD ” Practice Location

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