MEDICARE: TAVALLAEI, D.M.D., CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1134716939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAVALLAEI, D.M.D., CORPORATION

Provider Business Mailing Address
First Line	:	2260 E BIDWELL ST # 313
Second Line	:
City	:	FOLSOM
State	:	CA
Zip	:	95630-3555
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4060 DOUGLAS BLVD STE 110
Second Line	:
City	:	GRANITE BAY
State	:	CA
Zip	:	95746-5934
Country	:	US
Telephone Number	:	916-260-0646
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	MEGAN CASTILLO
Credential	:
Telephone Number	:	916-781-6550

Provider Enumeration Date	:	12/28/2020
Last Update Date	:	08/10/2022

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