Provider Demographics
NPI:1306856836
Name:MIREMAMI, ALI REZA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:REZA
Last Name:MIREMAMI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 ELLERSLIE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-5715
Mailing Address - Country:US
Mailing Address - Phone:859-421-5117
Mailing Address - Fax:859-381-5911
Practice Address - Street 1:1101 VETERANS DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-2235
Practice Address - Country:US
Practice Address - Phone:859-281-4912
Practice Address - Fax:859-381-5911
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY75961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice