Healthcare Provider Details

I. General information

NPI: 1063628816
Provider Name (Legal Business Name): TANDIS EFTEKHARI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 SAN JOAQUIN HILLS RD
NEWPORT BEACH CA
92660-6507
US

IV. Provider business mailing address

2105 SAN JOAQUIN HILLS RD
NEWPORT BEACH CA
92660-6507
US

V. Phone/Fax

Practice location:
  • Phone: 949-721-1730
  • Fax: 949-721-1709
Mailing address:
  • Phone: 949-721-1730
  • Fax: 949-721-1709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number52048
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: