Provider Demographics
NPI:1063801447
Name:TAHVILDARI, BITA
Entity type:Individual
Prefix:
First Name:BITA
Middle Name:
Last Name:TAHVILDARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3588 4TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4947
Mailing Address - Country:US
Mailing Address - Phone:619-295-5261
Mailing Address - Fax:619-295-5706
Practice Address - Street 1:3588 4TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4947
Practice Address - Country:US
Practice Address - Phone:619-295-5261
Practice Address - Fax:619-295-5706
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40776122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist