Provider Demographics
NPI:1174694640
Name:GERAYLI, AFSOON S (DDS)
Entity type:Individual
Prefix:
First Name:AFSOON
Middle Name:S
Last Name:GERAYLI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19231 VICTORY BLVD STE 451
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6360
Mailing Address - Country:US
Mailing Address - Phone:818-345-3355
Mailing Address - Fax:
Practice Address - Street 1:19231 VICTORY BLVD STE 451
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-6360
Practice Address - Country:US
Practice Address - Phone:818-345-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44402122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93913-01OtherMEDICAL PROVIDER NUMBER