Provider Demographics
NPI:1114439015
Name:FARDAD TAYEBATY DMD INC
Entity Type:Organization
Organization Name:FARDAD TAYEBATY DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FARDAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYEBATY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-875-3211
Mailing Address - Street 1:5700 VILLAGE OAKS DR APT 1408
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-3778
Mailing Address - Country:US
Mailing Address - Phone:617-875-3211
Mailing Address - Fax:
Practice Address - Street 1:390 S GREEN VALLEY RD STE 7
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-3077
Practice Address - Country:US
Practice Address - Phone:831-536-5880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1009121223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty