Provider Demographics
NPI:1679615264
Name:AIDIE, ALFRED (DMD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:AIDIE
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 1:1219 N PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-1619
Mailing Address - Country:US
Mailing Address - Phone:818-243-1000
Mailing Address - Fax:818-243-1159
Practice Address - Street 1:1219 N PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-1619
Practice Address - Country:US
Practice Address - Phone:818-243-1000
Practice Address - Fax:818-243-1159
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44811122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist