MEDICARE: ALI OSTADALI MAKHMALBAF

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	122300000X	Dentist	0401412149	VA
2	1223P0700X	Prosthodontics	59489	CA
3	1223P0700X	Prosthodontics	25978	TX

General Provider Information

NPI Number	:	1861640302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALI OSTADALI MAKHMALBAF

Provider Business Mailing Address
First Line	:	442 S PASEO SERENA
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92807-4214
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	925 W 34TH ST # 230
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-0058
Country	:	US
Telephone Number	:	714-495-0414
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2008
Last Update Date	:	09/11/2011

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