Provider Demographics
NPI:1932410420
Name:TAVAKOLI, FIONA M (DMD)
Entity type:Individual
Prefix:DR
First Name:FIONA
Middle Name:M
Last Name:TAVAKOLI
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 1:13478 CHELAN CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-4434
Mailing Address - Country:US
Mailing Address - Phone:904-859-8804
Mailing Address - Fax:
Practice Address - Street 1:5601 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3074
Practice Address - Country:US
Practice Address - Phone:619-462-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18890122300000X
CA63528122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist