Provider Demographics
NPI:1013205301
Name:TAVALLAEI, KIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIAN
Middle Name:
Last Name:TAVALLAEI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:FARZAD
Other - Middle Name:
Other - Last Name:TAVALLAEI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:533 MORAGA ROAD SUITE 230
Mailing Address - Street 2:
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94556
Mailing Address - Country:US
Mailing Address - Phone:925-376-0322
Mailing Address - Fax:925-376-0436
Practice Address - Street 1:533 MORAGA ROAD SUITE 230
Practice Address - Street 2:
Practice Address - City:MORAGA
Practice Address - State:CA
Practice Address - Zip Code:94556
Practice Address - Country:US
Practice Address - Phone:925-376-0322
Practice Address - Fax:925-376-0436
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60553122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist