Provider Demographics
NPI:1265815682
Name:FAZELI, AFSOON (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:AFSOON
Middle Name:
Last Name:FAZELI
Suffix:
Gender:F
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 1:2654 PEPPERTREE WAY
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-3073
Mailing Address - Country:US
Mailing Address - Phone:206-218-2010
Mailing Address - Fax:
Practice Address - Street 1:6221 METROPOLITAN ST STE 202
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-3096
Practice Address - Country:US
Practice Address - Phone:760-438-1279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106047122300000X
WADE605655421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Yes122300000XDental ProvidersDentist