Provider Demographics
NPI:1336712777
Name:FALLAHTAFTI, AFSANEH (DMD)
Entity type:Individual
Prefix:DR
First Name:AFSANEH
Middle Name:
Last Name:FALLAHTAFTI
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 1:936 S OLIVE ST APT 641
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3596
Mailing Address - Country:US
Mailing Address - Phone:949-423-5354
Mailing Address - Fax:
Practice Address - Street 1:936 S OLIVE ST APT 641
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3596
Practice Address - Country:US
Practice Address - Phone:949-423-5354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106341122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist