Provider Demographics
NPI:1013435023
Name:AHN, ALICE MIYAE
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:MIYAE
Last Name:AHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:MIYAE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:723 N GRAMERCY PL APT 21
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-4177
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:687 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-1349
Practice Address - Country:US
Practice Address - Phone:213-381-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1006161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice