Provider Demographics
NPI:1023842622
Name:ALIZADEH GHANNAD, AWA (DDS)
Entity type:Individual
Prefix:DR
First Name:AWA
Middle Name:
Last Name:ALIZADEH GHANNAD
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 1:1401 MISSION ST APT 802
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-2694
Mailing Address - Country:US
Mailing Address - Phone:916-420-4530
Mailing Address - Fax:
Practice Address - Street 1:914 ADMIRAL CALLAGHAN LN
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-3680
Practice Address - Country:US
Practice Address - Phone:707-674-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1105971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice