Provider Demographics
NPI:1376532440
Name:ALIYEVA, LATAFAT (DDS)
Entity Type:Individual
Prefix:
First Name:LATAFAT
Middle Name:
Last Name:ALIYEVA
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 1:8253 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2425
Mailing Address - Country:US
Mailing Address - Phone:215-745-5734
Mailing Address - Fax:
Practice Address - Street 1:8253 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2425
Practice Address - Country:US
Practice Address - Phone:215-745-5734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0359011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011099580001OtherMEDICAL ASSISTANCE
PA9177885OtherHEALTH PARTNERS