Provider Demographics
NPI:1669833810
Name:AZADEH AFZALI D.D.S, INC.
Entity Type:Organization
Organization Name:AZADEH AFZALI D.D.S, INC.
Other - Org Name:SB LIFETIME DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AZADEH
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:AFZALI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-881-3336
Mailing Address - Street 1:1918 BUSINESS CENTER DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3441
Mailing Address - Country:US
Mailing Address - Phone:909-881-3336
Mailing Address - Fax:909-890-9099
Practice Address - Street 1:1918 BUSINESS CENTER DR STE 210
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3441
Practice Address - Country:US
Practice Address - Phone:909-881-3336
Practice Address - Fax:909-890-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64657122300000X
CA550141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55014OtherCALIFORNIA DENTAL LICENCE
CA64657OtherCALIFORNIA DENTAL LICENCE