Healthcare Provider Details

I. General information

NPI: 1285643692
Provider Name (Legal Business Name): FARNAZ NICKI TAJALLI D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 WOODWAY DR STE 730
HOUSTON TX
77056-1847
US

IV. Provider business mailing address

13630 BEAMER RD SUITE 112
HOUSTON TX
77089-6069
US

V. Phone/Fax

Practice location:
  • Phone: 713-963-9191
  • Fax: 281-754-4352
Mailing address:
  • Phone: 281-481-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number18889
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: