MEDICARE: FARDAD TAYEBATY DMD

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	1223G0001X	General Practice Dentistry	22D102435200	NJ
2	1223E0200X	Endodontics	100912	CA
3	1223E0200X	Endodontics	22DI02435200	NJ
4	1223E0200X	Endodontics	055815	NY
5	1223G0001X	General Practice Dentistry	22292	MA

General Provider Information

NPI Number	:	1396908943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FARDAD TAYEBATY DMD

Provider Business Mailing Address
First Line	:	390 S GREEN VALLEY RD STE 7
Second Line	:
City	:	WATSONVILLE
State	:	CA
Zip	:	95076-3077
Country	:	US
Telephone Number	:	617-875-3211
Fax Number	:

Provider Business Practice Location Address
First Line	:	390 S GREEN VALLEY RD STE 7
Second Line	:
City	:	WATSONVILLE
State	:	CA
Zip	:	95076-3077
Country	:	US
Telephone Number	:	617-875-3211
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2008
Last Update Date	:	04/09/2018

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Practice Fax:

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