Healthcare Provider Details

I. General information

NPI: 1093780603
Provider Name (Legal Business Name): TIRBOD TODD FATTAHI M.D. , DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2006
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST UFJP ORAL SURGERY
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

PO BOX 44008 UFJP PROVIDER ENROLLMENT
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-3901
  • Fax: 904-244-3218
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDTP368
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberME85119
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: