Provider Demographics
NPI:1508065194
Name:ALAVIZADEH, ASHLEY MARMAR
Entity Type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:MARMAR
Last Name:ALAVIZADEH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370265
Mailing Address - Street 2:#202
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91337-0265
Mailing Address - Country:US
Mailing Address - Phone:214-293-1597
Mailing Address - Fax:
Practice Address - Street 1:9906 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-3207
Practice Address - Country:US
Practice Address - Phone:562-803-9600
Practice Address - Fax:562-803-1025
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55844122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD55844Medicaid