MEDICARE: DR. NELLIE PETRONELLA TAZBAZ D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	45331	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B4533101	OTHER	CA	DENTI-CAL
2	B4533101	OTHER	CA	HEALTHY FAMILIES/DELTA

General Provider Information

NPI Number	:	1366468753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NELLIE PETRONELLA TAZBAZ D.D.S.

Provider Business Mailing Address
First Line	:	3796 CLAIREMONT DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-5916
Country	:	US
Telephone Number	:	858-273-5788
Fax Number	:	858-273-5337

Provider Business Practice Location Address
First Line	:	3796 CLAIREMONT DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-5916
Country	:	US
Telephone Number	:	858-273-5788
Fax Number	:	858-273-5337

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	03/13/2008

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