MEDICARE: DR. HADI KHAZAAL DDS, MD

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	30.025831	OH
2	390200000X	Student in an Organized Health Care Education/Training Program
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	2901600195	MI

General Provider Information

NPI Number	:	1407413180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HADI KHAZAAL DDS, MD

Provider Business Mailing Address
First Line	:	217 S BEECH DALY ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48125-1079
Country	:	US
Telephone Number	:	313-460-1881
Fax Number	:

Provider Business Practice Location Address
First Line	:	50154 SCHOENHERR RD
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48315-3136
Country	:	US
Telephone Number	:	586-731-9050
Fax Number	:

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

Provider Enumeration Date	:	05/28/2019
Last Update Date	:	07/15/2024

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