Provider Demographics
NPI:1285643692
Name:TAJALLI, FARNAZ NICKI (DDS)
Entity type:Individual
Prefix:DR
First Name:FARNAZ
Middle Name:NICKI
Last Name:TAJALLI
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 1:13630 BEAMER RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-6069
Mailing Address - Country:US
Mailing Address - Phone:281-481-2273
Mailing Address - Fax:
Practice Address - Street 1:4900 WOODWAY DR STE 730
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77056-1847
Practice Address - Country:US
Practice Address - Phone:713-963-9191
Practice Address - Fax:281-754-4352
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18889122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX320050821OtherTIN