Provider Demographics
NPI:1053724120
Name:KHANUM, SHAMINA (DENTIST)
Entity type:Individual
Prefix:MS
First Name:SHAMINA
Middle Name:
Last Name:KHANUM
Suffix:
Gender:F
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3502 WEST NORTHSIDE DRIVE, JACKSON HINDS COMPREHENSIVE
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801
Mailing Address - Country:US
Mailing Address - Phone:601-362-5321
Mailing Address - Fax:601-364-2600
Practice Address - Street 1:3502 WEST NORTHSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213
Practice Address - Country:US
Practice Address - Phone:601-362-5321
Practice Address - Fax:601-364-2600
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4090-191223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice