Provider Demographics
NPI:1669532925
Name:VAZIRI, ALI (DDS)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:VAZIRI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4706
Mailing Address - Country:US
Mailing Address - Phone:310-391-6311
Mailing Address - Fax:310-390-1874
Practice Address - Street 1:859 VIA DE LA PAZ
Practice Address - Street 2:SUITE C
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3664
Practice Address - Country:US
Practice Address - Phone:310-230-8282
Practice Address - Fax:310-230-8292
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA393481223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB39348-01Medicaid