MEDICARE: ENAS AL-KHADRA 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	1223P0221X	Pediatric Dentistry	DN16650	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588672430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ENAS AL-KHADRA DDS

Provider Business Mailing Address
First Line	:	4800 NE 20TH TER STE 301
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-4510
Country	:	US
Telephone Number	:	954-727-9865
Fax Number	:	954-727-9940

Provider Business Practice Location Address
First Line	:	4800 NE 20TH TER STE 301
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-4510
Country	:	US
Telephone Number	:	954-727-9865
Fax Number	:	954-727-9940

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

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	06/29/2010

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