=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205493624
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YASAMIN TARASSOLI, DDS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2019
-----------------------------------------------------
Last Update Date | 05/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1175 ARNOLD DR STE C
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94553-4111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-229-3232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4140 WHISPERING OAKS LN
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94506-5838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-469-3138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER/PRESIDENT
-----------------------------------------------------
Name | DR. YASAMIN TARASSOLI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-469-3138
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------