Provider Demographics
NPI:1417010232
Name:GANJI, AMIR ALI (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMIR
Middle Name:ALI
Last Name:GANJI
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 1:1424 S BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-2154
Mailing Address - Country:US
Mailing Address - Phone:506-624-5590
Mailing Address - Fax:509-747-0483
Practice Address - Street 1:1424 S BERNARD ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-2154
Practice Address - Country:US
Practice Address - Phone:506-624-5590
Practice Address - Fax:509-747-0483
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA79941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5028964Medicaid