Provider Demographics
NPI:1528715570
Name:MARK TAVAKOLI DDS DENTAL CORPORATION
Entity type:Organization
Organization Name:MARK TAVAKOLI DDS DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:MAJID
Authorized Official - Last Name:TAVAKOLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:925-285-2125
Mailing Address - Street 1:2210 LOCH LN
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3369
Mailing Address - Country:US
Mailing Address - Phone:925-285-2125
Mailing Address - Fax:
Practice Address - Street 1:485 34TH ST STE 102
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2823
Practice Address - Country:US
Practice Address - Phone:925-285-2125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental