Provider Demographics
NPI:1104552231
Name:TAVAKOLIAN DDS, INC.
Entity type:Organization
Organization Name:TAVAKOLIAN DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PARDIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVAKOLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:240-750-9239
Mailing Address - Street 1:2041 PIONEER CT STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1729
Mailing Address - Country:US
Mailing Address - Phone:650-573-0628
Mailing Address - Fax:650-345-2677
Practice Address - Street 1:2041 PIONEER CT STE 100
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1729
Practice Address - Country:US
Practice Address - Phone:240-750-9239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-30
Last Update Date:2022-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1932656949OtherNPI TYPE 1