MEDICARE: MARIAM KHELLA DDS

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	D15174	MN
2	122300000X	Dentist	D15174	MN

General Provider Information

NPI Number	:	1396575635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAM KHELLA DDS

Provider Business Mailing Address
First Line	:	948 CONEFLOWER CT
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55123-3978
Country	:	US
Telephone Number	:	651-447-9835
Fax Number	:

Provider Business Practice Location Address
First Line	:	9042 CAHILL AVE
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55076-3543
Country	:	US
Telephone Number	:	651-457-8282
Fax Number	:

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

Provider Enumeration Date	:	08/02/2024
Last Update Date	:	08/02/2024

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