Provider Demographics
NPI:1053428755
Name:KHODABAKHSH, SASAN (DDS)
Entity type:Individual
Prefix:DR
First Name:SASAN
Middle Name:
Last Name:KHODABAKHSH
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 1:3124 W UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-3018
Mailing Address - Country:US
Mailing Address - Phone:694-625-0005
Mailing Address - Fax:
Practice Address - Street 1:3124 W UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-3018
Practice Address - Country:US
Practice Address - Phone:694-625-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173282809Medicaid