=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245565159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YASAMIN TARASSOLI DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2009
-----------------------------------------------------
Last Update Date | 11/05/2021
-----------------------------------------------------
=====================================================
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 | 925-228-1420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1175 ARNOLD DR STE C
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94553-4111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-229-3232
-----------------------------------------------------
Fax | 925-228-1420
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 58745
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------