Provider Demographics
NPI:1558036459
Name:DALLALZADEH, STACEY LEILA (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LEILA
Last Name:DALLALZADEH
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 1:4617 DEGOVIA AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-3713
Mailing Address - Country:US
Mailing Address - Phone:818-675-4091
Mailing Address - Fax:
Practice Address - Street 1:4617 DEGOVIA AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-3713
Practice Address - Country:US
Practice Address - Phone:818-675-4091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1068251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice