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General NPI Number Information
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NPI Number | 1740795657
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Entity Type | Organization
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Legal Business Name | TAVALLAEI, D.M.D., CORPORATION
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Dates
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Enumeration Date | 12/14/2017
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Last Update Date | 12/15/2017
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Provider Practice Location Address
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Address Line | 1955 W TEXAS ST STE 2A
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City | FAIRFIELD
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State | CA
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Zip | 94533-4462
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Country | US
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Telephone | 916-707-7973
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Fax |
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Provider Business Mailing Address
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Address Line | 2260 E BIDWELL ST # 311
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City | FOLSOM
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State | CA
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Zip | 95630-3555
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Country | US
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Telephone | 916-781-6550
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MEGAN CASTILLO
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Credential |
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Telephone | 916-781-6550
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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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