Provider Demographics
NPI:1295957496
Name:FAZELI, LEYLA (DMD)
Entity type:Individual
Prefix:MRS
First Name:LEYLA
Middle Name:
Last Name:FAZELI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 S BRISTOL STREET
Mailing Address - Street 2:STE 103
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704
Mailing Address - Country:US
Mailing Address - Phone:714-432-0979
Mailing Address - Fax:714-432-1279
Practice Address - Street 1:3620 S BRISTOL STREET
Practice Address - Street 2:STE 103
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704
Practice Address - Country:US
Practice Address - Phone:714-432-0979
Practice Address - Fax:714-432-1279
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48453122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist