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General NPI Number Information
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NPI Number | 1366054348
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Entity Type | Individual
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Provider Name | ETHAR RIYADH AL-WAZEER DDS
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Gender | Female
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Dates
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Enumeration Date | 08/20/2020
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Last Update Date | 09/11/2020
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Provider Practice Location Address
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Address Line | 10144 SIERRA AVE
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City | FONTANA
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State | CA
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Zip | 92335-6725
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Country | US
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Telephone | 909-770-7367
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Fax |
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Provider Business Mailing Address
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Address Line | 1510 ORANGE AVE APT 304
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City | REDLANDS
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State | CA
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Zip | 92373-1493
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Country | US
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Telephone | 630-408-9723
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 105309
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License Number State | CA
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