Provider Demographics
NPI:1700368792
Name:ALEEMUDDIN, AZAM MOHAMMED (DDS, MPH)
Entity Type:Individual
Prefix:DR
First Name:AZAM
Middle Name:MOHAMMED
Last Name:ALEEMUDDIN
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21050 STONYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-5012
Mailing Address - Country:US
Mailing Address - Phone:951-907-5694
Mailing Address - Fax:
Practice Address - Street 1:1965 FOOTHILL BLVD STE L
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3502
Practice Address - Country:US
Practice Address - Phone:909-596-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2023-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33936122300000X
CADDS1074221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist