Provider Demographics
NPI:1679148365
Name:KHAN, RYEED ALI
Entity type:Individual
Prefix:
First Name:RYEED
Middle Name:ALI
Last Name:KHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 GRASSY HILL RD
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-1009
Mailing Address - Country:US
Mailing Address - Phone:860-912-0157
Mailing Address - Fax:
Practice Address - Street 1:339 FLANDERS RD STE 105
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1729
Practice Address - Country:US
Practice Address - Phone:860-691-0025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT133321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice