Healthcare Provider Details

I. General information

NPI: 1104660687
Provider Name (Legal Business Name): AMROLLAHIE DMD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 DURIAN ST STE C
VISTA CA
92083-6240
US

IV. Provider business mailing address

105 DURIAN ST STE C
VISTA CA
92083-6240
US

V. Phone/Fax

Practice location:
  • Phone: 760-733-8080
  • Fax: 760-276-7888
Mailing address:
  • Phone: 760-733-8080
  • Fax: 760-276-7888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. ALI AMROLLAHIE
Title or Position: PRESIDENT
Credential:
Phone: 949-510-7795