Provider Demographics
NPI:1821183864
Name:KHANSARI, ALIREZA (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:ALIREZA
Middle Name:
Last Name:KHANSARI
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 REGENTS PARK ROW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9124
Mailing Address - Country:US
Mailing Address - Phone:858-587-9077
Mailing Address - Fax:858-587-4633
Practice Address - Street 1:4150 REGENTS PARK ROW
Practice Address - Street 2:SUITE 100
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9124
Practice Address - Country:US
Practice Address - Phone:858-587-9077
Practice Address - Fax:858-587-4633
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA495901223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics