MEDICARE: MARY AFZALI,D.D.S.,INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	39224	CA

General Provider Information

NPI Number	:	1235258419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY AFZALI,D.D.S.,INC.

Provider Business Mailing Address
First Line	:	16776 BERNARDO CENTER DR
Second Line	:	SUITE 105
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-2534
Country	:	US
Telephone Number	:	858-485-0044
Fax Number	:	858-485-8150

Provider Business Practice Location Address
First Line	:	16776 BERNARDO CENTER DR
Second Line	:	SUITE 105
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-2534
Country	:	US
Telephone Number	:	858-485-0044
Fax Number	:	858-485-8150

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARYAM Z AFZALI
Credential	:	DDS
Telephone Number	:	858-485-0044

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	07/23/2015

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