Khin Mimi San, BCHD

Primary specialty

PeriodonticsTaxonomy code 1223P0300X

License

0401416690 Issued in VA

Practice address

477 Viking Drive
Suite 190
VA Beach, VA 23452-7354

Phone

(757) 486-8181

Fax

(757) 463-0148

NPI assigned

Nov 15, 2016

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Aug 8, 2019 through Aug 8, 2027

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Konikoff Periodontics LTD

  • Periodontics
  • Virginia Beach, VA
  • NPI 1477706737
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1479168000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1621555200000",
    "number": "1689116113",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "477 VIKING DRIVE",
            "address_2": "SUITE 190",
            "city": "VA BEACH",
            "state": "VA",
            "postal_code": "234527354",
            "telephone_number": "757-486-8181",
            "fax_number": "757-463-0148"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "477 VIKING DRIVE",
            "address_2": "SUITE 190",
            "city": "VA BEACH",
            "state": "VA",
            "postal_code": "234527354",
            "telephone_number": "757-486-8181",
            "fax_number": "757-463-0148"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SAN",
        "first_name": "KHIN MIMI",
        "name_prefix": "Ms.",
        "credential": "BCHD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2016-11-15",
        "last_updated": "2021-05-21",
        "certification_date": "2021-05-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "",
            "desc": "Dentist, Periodontics",
            "state": "VA",
            "license": "0401416690",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Shelly Marie Rodgers, LPC
• Deborah Lynn Roebuck, DC
• Precious Kenora Rowe
• Royal Hearts Homecare LLC
• Safe Haven Residential Care
• Paul F. Schellhammer, M.D.
• Yardan Shabazz II, RBT
• April M Shackleford, MD
• Allysin Sheeley
• Simply Amazing Transport LLC

• Periodontics in VA Beach, VA
• Providers in VA Beach, VA by specialty
• Periodontics in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 21, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.