Provider Demographics
NPI:1366818353
Name:AFZALI, MARYAM (DDS)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:AFZALI
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 1:16776 BERNARDO CENTER DR STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2558
Mailing Address - Country:US
Mailing Address - Phone:858-485-0044
Mailing Address - Fax:
Practice Address - Street 1:16776 BERNARDO CENTER DR STE 105
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2558
Practice Address - Country:US
Practice Address - Phone:858-485-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39224122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist