Provider Demographics
NPI:1194041533
Name:ELI TABARAI, DMD DENTAL CORPORATION, A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:ELI TABARAI, DMD DENTAL CORPORATION, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELI
Authorized Official - Middle Name:
Authorized Official - Last Name:TABARIAI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:310-415-3521
Mailing Address - Street 1:PO BOX 24530
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-0530
Mailing Address - Country:US
Mailing Address - Phone:310-415-3521
Mailing Address - Fax:323-544-2994
Practice Address - Street 1:11980 SAN VICENTE BLVD STE 802
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6606
Practice Address - Country:US
Practice Address - Phone:310-415-3521
Practice Address - Fax:323-544-2994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-09
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA193400000XOtherSIGLE SPECIALTY GROUP
CA1223S0112XOtherDENTIST- ORAL AND MAXILLOFACIAL SURGERY