Provider Demographics
NPI:1952391393
Name:ALI, MARY (DDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ALI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S FAIRMONT AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240
Mailing Address - Country:US
Mailing Address - Phone:209-369-2696
Mailing Address - Fax:209-369-6743
Practice Address - Street 1:525 S FAIRMONT AVE
Practice Address - Street 2:SUITE H
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240
Practice Address - Country:US
Practice Address - Phone:209-369-2696
Practice Address - Fax:209-369-6743
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA502011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
BA8064975OtherDEA