MEDICARE: BITA TAHVILDARI, D.D.S.

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	40776	CA

General Provider Information

NPI Number	:	1376988675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BITA TAHVILDARI, D.D.S.

Provider Business Mailing Address
First Line	:	3588 4TH AVE
Second Line	:	SUITE 300
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4981
Country	:	US
Telephone Number	:	619-295-5261
Fax Number	:	619-295-5706

Provider Business Practice Location Address
First Line	:	3588 4TH AVE
Second Line	:	SUITE 300
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4981
Country	:	US
Telephone Number	:	619-295-5261
Fax Number	:	619-295-5706

Authorized Official
Title or Position	:	OWNER
Name	:	BITA TAHVILDARI
Credential	:	DDS
Telephone Number	:	619-295-5261

Provider Enumeration Date	:	05/01/2013
Last Update Date	:	09/03/2013

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