Provider Demographics
NPI:1558612945
Name:KHAZALI, MARAL (DDS)
Entity Type:Individual
Prefix:
First Name:MARAL
Middle Name:
Last Name:KHAZALI
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 1:5820 HAZELTINE AVE APT 21
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-3710
Mailing Address - Country:US
Mailing Address - Phone:310-606-0725
Mailing Address - Fax:
Practice Address - Street 1:5771 PINE AVE STE S
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-6529
Practice Address - Country:US
Practice Address - Phone:909-597-2477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61929122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist