Healthcare Provider Details

I. General information

NPI: 1497326862
Provider Name (Legal Business Name): ALI AMIR KHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 07/07/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7210 DAY CREEK BLVD STE 110
RANCHO CUCAMONGA CA
91739-7543
US

IV. Provider business mailing address

12121 WILSHIRE BLVD STE 1111
LOS ANGELES CA
90025-1188
US

V. Phone/Fax

Practice location:
  • Phone: 909-803-1111
  • Fax:
Mailing address:
  • Phone: 310-820-9933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number106457
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: