Provider Demographics
NPI:1043350671
Name:KHOLAKI, MOHAMAD SALEH (DDS)
Entity type:Individual
Prefix:DR
First Name:MOHAMAD
Middle Name:SALEH
Last Name:KHOLAKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 HUNTINGTON DR
Mailing Address - Street 2:#5
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-2404
Mailing Address - Country:US
Mailing Address - Phone:626-301-4220
Mailing Address - Fax:626-301-4223
Practice Address - Street 1:1230 HUNTINGTON DR
Practice Address - Street 2:#5
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-2404
Practice Address - Country:US
Practice Address - Phone:626-301-4220
Practice Address - Fax:626-301-4223
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADA0333011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice