Healthcare Provider Details

I. General information

NPI: 1659753762
Provider Name (Legal Business Name): T SIDAL DDS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12395 EL CAMINO REAL, SUITE 304 TORREY PINES ORAL & MAXILLOFACIAL SURGERY
SAN DIEGO CA
92130
US

IV. Provider business mailing address

12395 EL CAMINO REAL, SUITE 304 TORREY PINES ORAL & MAXILLOFACIAL SURGERY
SAN DIEGO CA
92130
US

V. Phone/Fax

Practice location:
  • Phone: 858-793-3393
  • Fax:
Mailing address:
  • Phone: 858-793-3393
  • 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 TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberA122601
License Number StateCA

VIII. Authorized Official

Name: DR. TARKAN SIDAL
Title or Position: PRESIDENT
Credential: DDS,MD
Phone: 312-505-8656