Provider Demographics
NPI:1548588486
Name:LAALY, FARAZ FRED (DDS)
Entity Type:Individual
Prefix:DR
First Name:FARAZ
Middle Name:FRED
Last Name:LAALY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 W CLARK AVE APT A
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-2952
Mailing Address - Country:US
Mailing Address - Phone:310-210-6955
Mailing Address - Fax:
Practice Address - Street 1:4301 N FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90065-3013
Practice Address - Country:US
Practice Address - Phone:323-223-1517
Practice Address - Fax:323-223-1528
Is Sole Proprietor?:No
Enumeration Date:2010-05-15
Last Update Date:2010-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43626122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist