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NPI Code Detail

MEDICARE: MARYAM KHALILI DDS-PROSTHODONTIST

MEDICARE: MARYAM KHALILI DDS-PROSTHODONTIST
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
11223P0700XProsthodonticsDS045634PA
2122300000XDentist34590TX
3122300000XDentist0401416303VA

General Provider Information

NPI Number : 1578101630
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARYAM KHALILI DDS-PROSTHODONTIST
Provider Business Mailing Address
First Line : 545 N BROAD ST
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19123-3592
Country : US
Telephone Number : 215-874-7611
Fax Number :
Provider Business Practice Location Address
First Line : 3223 N BROAD ST OFC 314
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19140-5007
Country : US
Telephone Number : 773-807-9934
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/19/2019
Last Update Date : 05/21/2026

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Directions to “ MARYAM KHALILI DDS-PROSTHODONTIST” Practice Location

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