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General NPI Number Information
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NPI Number | 1417399502
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Entity Type | Organization
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Legal Business Name | TAVALLAEI DMD CORP
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Dates
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Enumeration Date | 07/18/2013
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Last Update Date | 08/04/2022
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Provider Practice Location Address
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Address Line | 731 STERLING PKWY SUITE 100
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City | LINCOLN
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State | CA
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Zip | 95648-7306
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Country | US
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Telephone | 916-258-7639
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Fax | 916-983-9012
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Provider Business Mailing Address
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Address Line | 2260 E BIDWELL ST SUITE 310
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City | FOLSOM
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State | CA
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Zip | 95630-3463
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Country | US
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Telephone | 916-258-7639
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Fax | 916-983-9012
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Authorized Official
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Title or Position | OWNER
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Name | DR. MONICA TAVALLAEI
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Credential |
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Telephone | 916-258-7639
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 48036
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License Number State | CA
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