Healthcare Provider Details

I. General information

NPI: 1013068782
Provider Name (Legal Business Name): ALI HARANDIFASSIH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 VIRGINIA AVENUE SUITE A
HAPEVILLE GA
30354
US

IV. Provider business mailing address

785 VIRGINIA AVENUE SUITE A
HAPEVILLE GA
30354
US

V. Phone/Fax

Practice location:
  • Phone: 404-768-8700
  • Fax: 404-768-8588
Mailing address:
  • Phone: 404-768-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN011520
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: