Healthcare Provider Details

I. General information

NPI: 1407036502
Provider Name (Legal Business Name): TARKAN SIDAL DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8008 FROST ST SUITE 311
SAN DIEGO CA
92123-4205
US

IV. Provider business mailing address

8008 FROST ST SUITE 311
SAN DIEGO CA
92123-4205
US

V. Phone/Fax

Practice location:
  • Phone: 858-292-6033
  • Fax:
Mailing address:
  • Phone: 858-292-6033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberOMS 101
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019-027754
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberA122601
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: