Provider Demographics
NPI:1073708582
Name:AGHALOO, JAVAD SAGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAVAD
Middle Name:SAGE
Last Name:AGHALOO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 S. LA BRUCHERIE RD.
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243
Mailing Address - Country:US
Mailing Address - Phone:760-482-5505
Mailing Address - Fax:760-482-5501
Practice Address - Street 1:1502 S. LA BRUCHERIE RD.
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243
Practice Address - Country:US
Practice Address - Phone:760-482-5505
Practice Address - Fax:760-482-5501
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-07
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51184122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist