Basic Information
| Provider Information | |||||||||
| NPI: | 1447805973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | AQIB | ||||||||
| MiddleName: | NAWAZ | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | USA DENTAL ACTIVITY ATTN: CREDENTIALS | ||||||||
| Address2: | 2901 CASSIDY RD | ||||||||
| City: | FORT BLISS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157425935 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | USA DENTAL ACTIVITY | ||||||||
| Address2: | 2901 CASSIDY RD | ||||||||
| City: | FORT BLISS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157425935 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2019 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D14252 | MN | Y | Dental Providers | Dentist |
No ID Information.