Provider Demographics
NPI:1366201097
Name:ROBERTS, KHANZI (RDH)
Entity type:Individual
Prefix:
First Name:KHANZI
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2875 TROY CENTER DR APT P-31
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4758
Mailing Address - Country:US
Mailing Address - Phone:816-255-5334
Mailing Address - Fax:
Practice Address - Street 1:4909 E OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-3446
Practice Address - Country:US
Practice Address - Phone:313-366-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902020690124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist