Provider Demographics
NPI:1417399502
Name:TAVALLAEI DMD CORP
Entity type:Organization
Organization Name:TAVALLAEI DMD CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVALLAEI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-258-7639
Mailing Address - Street 1:2260 E BIDWELL ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3463
Mailing Address - Country:US
Mailing Address - Phone:916-258-7639
Mailing Address - Fax:916-983-9012
Practice Address - Street 1:731 STERLING PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-7306
Practice Address - Country:US
Practice Address - Phone:916-258-7639
Practice Address - Fax:916-983-9012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-18
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA480361223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty