Provider Demographics
NPI:1366054348
Name:AL-WAZEER, ETHAR RIYADH (DDS)
Entity type:Individual
Prefix:
First Name:ETHAR
Middle Name:RIYADH
Last Name:AL-WAZEER
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 1:1510 ORANGE AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-1493
Mailing Address - Country:US
Mailing Address - Phone:630-408-9723
Mailing Address - Fax:
Practice Address - Street 1:10144 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6725
Practice Address - Country:US
Practice Address - Phone:909-770-7367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105309122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist