Provider Demographics
NPI:1720275217
Name:KHOSROVANI, ALI M (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:M
Last Name:KHOSROVANI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:ALI
Other - Middle Name:M
Other - Last Name:KHOSROVANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4905 YORK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-1609
Mailing Address - Country:US
Mailing Address - Phone:323-255-8774
Mailing Address - Fax:323-255-6259
Practice Address - Street 1:4905 YORK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-2022
Practice Address - Country:US
Practice Address - Phone:310-968-9192
Practice Address - Fax:310-575-9822
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56085122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist