Provider Demographics
NPI:1629196449
Name:ARDALAN, SOUZAN R
Entity Type:Individual
Prefix:DR
First Name:SOUZAN
Middle Name:R
Last Name:ARDALAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2554 ARDMORE AVE
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2224
Mailing Address - Country:US
Mailing Address - Phone:714-480-3000
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:530 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4525
Practice Address - Country:US
Practice Address - Phone:714-480-3000
Practice Address - Fax:714-571-3560
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40302122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD40302Medicaid