Provider Demographics
NPI:1598019739
Name:ETEMADIEH, ALI-REZA
Entity Type:Individual
Prefix:DR
First Name:ALI-REZA
Middle Name:
Last Name:ETEMADIEH
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 1:665 N TUSTIN ST STE W
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-7148
Mailing Address - Country:US
Mailing Address - Phone:714-628-9910
Mailing Address - Fax:
Practice Address - Street 1:665 N TUSTIN ST STE W
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-7148
Practice Address - Country:US
Practice Address - Phone:714-628-9910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61311122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist