Active NPI
Mark I Khaimov, DDS
- Periodontics
- Nutley, NJ
National Provider Identifier
1477614162
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Periodontics
- License
- 2249201
- Practice address
- 180 Centre St
Nutley, NJ 07110-2828 - Phone
- (973) 798-2639
- Fax
- (973) 798-2640
- NPI assigned
- Dec 13, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Periodontics | 1223P0300X | 2249201 | NJ | Primary |
Addresses
Primary practice location
180 Centre St
Nutley, NJ 07110-2828
Mailing address
180 Centre St
Nutley, NJ 07110-2828
Phone (973) 798-2639
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2249201 | NJ | MD | Periodontist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1165968000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1468800000000",
"number": "1477614162",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "180 CENTRE ST",
"city": "NUTLEY",
"state": "NJ",
"postal_code": "071102828",
"telephone_number": "973-798-2639",
"fax_number": "973-798-2640"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "180 CENTRE ST",
"city": "NUTLEY",
"state": "NJ",
"postal_code": "071102828",
"telephone_number": "973-798-2639",
"fax_number": "973-798-2640"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KHAIMOV",
"first_name": "MARK",
"middle_name": "I",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-12-13",
"last_updated": "2016-07-18",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0300X",
"taxonomy_group": "",
"desc": "Dentist, Periodontics",
"state": "NJ",
"license": "2249201",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Nutley, NJ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 18, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.