Provider Demographics
NPI:1326350851
Name:AFZALI, PAYAM (DDS, MD)
Entity Type:Individual
Prefix:
First Name:PAYAM
Middle Name:
Last Name:AFZALI
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11962 STONEY PEAK DR APT 1222
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-6483
Mailing Address - Country:US
Mailing Address - Phone:619-335-0875
Mailing Address - Fax:
Practice Address - Street 1:11962 STONEY PEAK DR APT 1222
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-6483
Practice Address - Country:US
Practice Address - Phone:619-335-0875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA590551223S0112X
MI4301110260390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery