=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528715570
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK TAVAKOLI DDS DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2022
-----------------------------------------------------
Last Update Date | 03/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 485 34TH ST STE 102
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94609-2823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-285-2125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2210 LOCH LN
-----------------------------------------------------
City | WALNUT CREEK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94598-3369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-285-2125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. MARK MAJID TAVAKOLI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 925-285-2125
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------