Provider Demographics
NPI:1578631800
Name:REZKALLA, ATEF R
Entity Type:Individual
Prefix:
First Name:ATEF
Middle Name:R
Last Name:REZKALLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-3536
Mailing Address - Country:US
Mailing Address - Phone:562-436-4214
Mailing Address - Fax:562-435-3067
Practice Address - Street 1:11481 ROSECRANS AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-3830
Practice Address - Country:US
Practice Address - Phone:562-863-3457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA480041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice