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General NPI Number Information
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NPI Number | 1871752915
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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 | 06/04/2008
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Last Update Date | 04/12/2016
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Provider Practice Location Address
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Address Line | 2241 SUNSET BLVD SUITE D
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City | ROCKLIN
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State | CA
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Zip | 95765-4295
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Country | US
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Telephone | 916-380-0102
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Fax | 916-983-9012
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Provider Business Mailing Address
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Address Line | 2241 SUNSET BLVD SUITE D
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City | ROCKLIN
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State | CA
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Zip | 95765-4295
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Country | US
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Telephone | 916-380-0102
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Fax | 916-983-9012
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. MONICA TAVALLAEI
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Credential | DMD
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Telephone | 916-380-0102
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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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