Healthcare Provider Details

I. General information

NPI: 1932410420
Provider Name (Legal Business Name): FIONA M TAVAKOLI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 03/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 GROSSMONT CENTER DR
LA MESA CA
91942-3074
US

IV. Provider business mailing address

13478 CHELAN CT
SAN DIEGO CA
92129-4434
US

V. Phone/Fax

Practice location:
  • Phone: 619-462-2272
  • Fax:
Mailing address:
  • Phone: 904-859-8804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number18890
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number63528
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: