Provider Demographics
NPI:1861640302
Name:OSTADALI MAKHMALBAF, ALI
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:OSTADALI MAKHMALBAF
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 1:442 S PASEO SERENA
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:925 W 34TH ST # 230
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0058
Practice Address - Country:US
Practice Address - Phone:714-495-0414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2011-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412149122300000X
CA594891223P0700X
TX259781223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist