Provider Demographics
NPI:1619154267
Name:ARDALAN, CYROUS (DMD)
Entity Type:Individual
Prefix:DR
First Name:CYROUS
Middle Name:
Last Name:ARDALAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 17TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-4766
Mailing Address - Country:US
Mailing Address - Phone:617-686-6629
Mailing Address - Fax:
Practice Address - Street 1:8723 ALDEN DRIVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048
Practice Address - Country:US
Practice Address - Phone:310-423-6361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56760122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist