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General NPI Number Information
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NPI Number | 1588723951
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Entity Type | Organization
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Legal Business Name | ALIREZA
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Dates
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Enumeration Date | 12/08/2006
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Last Update Date | 02/22/2010
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Provider Practice Location Address
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Address Line | 13422 POMERADO RD STE 202
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City | POWAY
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State | CA
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Zip | 92064-3548
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Country | US
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Telephone | 858-679-0142
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Fax | 858-679-0165
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Provider Business Mailing Address
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Address Line | PO BOX 1334
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City | POWAY
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State | CA
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Zip | 92074-1334
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Country | US
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Telephone | 858-679-0142
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Fax | 858-679-0165
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Authorized Official
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Title or Position | PERIODONTIST
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Name | DR. ALIREZA KHANSARI
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Credential | DDS, MSD
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Telephone | 858-679-0142
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State | CA
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