=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184780587
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAVALLAEI, D.M.D., CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2006
-----------------------------------------------------
Last Update Date | 08/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3840 EL DORADO HILLS BLVD SUITE 203
-----------------------------------------------------
City | EL DORADO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95762-4567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-941-0303
-----------------------------------------------------
Fax | 916-983-9012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3840 EL DORADO HILLS BLVD SUITE 203
-----------------------------------------------------
City | EL DORADO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95762-4567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-941-0303
-----------------------------------------------------
Fax | 916-983-9012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRIC DENTIST
-----------------------------------------------------
Name | MONICA TAVALLAEI
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 916-941-0303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 48036
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------