Provider Demographics
NPI:1750641262
Name:AYALA, ALFREDO
Entity Type:Individual
Prefix:
First Name:ALFREDO
Middle Name:
Last Name:AYALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15862 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-2512
Mailing Address - Country:US
Mailing Address - Phone:562-943-3939
Mailing Address - Fax:562-943-3737
Practice Address - Street 1:15862 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-2512
Practice Address - Country:US
Practice Address - Phone:562-943-3939
Practice Address - Fax:562-943-3737
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2022-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60792122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist