Provider Demographics
NPI:1174744387
Name:MAHJOORY-KHAN, ATOSA
Entity type:Individual
Prefix:
First Name:ATOSA
Middle Name:
Last Name:MAHJOORY-KHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 HAMPTON POINT DR
Mailing Address - Street 2:SUITE 1 & 2
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3059
Mailing Address - Country:US
Mailing Address - Phone:904-230-5590
Mailing Address - Fax:904-230-5591
Practice Address - Street 1:163 HAMPTON POINT DR
Practice Address - Street 2:SUITE 1 & 2
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3059
Practice Address - Country:US
Practice Address - Phone:904-230-5590
Practice Address - Fax:904-230-5591
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 14201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist