Provider Demographics
NPI:1699434985
Name:TAHSILI FAHADAN, TANIA (DMD)
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:TAHSILI FAHADAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W COMMONWEALTH AVE APT 217
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-3720
Mailing Address - Country:US
Mailing Address - Phone:310-717-2904
Mailing Address - Fax:
Practice Address - Street 1:3851 KATELLA AVE STE 225
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3353
Practice Address - Country:US
Practice Address - Phone:562-285-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1071571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice