MEDICARE: MR. JALALUDDIN KHIMANI D.D.S.

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		IL

General Provider Information

NPI Number	:	1316098817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JALALUDDIN KHIMANI D.D.S.

Provider Business Mailing Address
First Line	:	5408 RITA AVE
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3882
Country	:	US
Telephone Number	:	815-356-7962
Fax Number	:

Provider Business Practice Location Address
First Line	:	820 E TERRA COTTA AVE
Second Line	:	SUITE 203
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3649
Country	:	US
Telephone Number	:	815-444-1549
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2007
Last Update Date	:	07/08/2007

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