Provider Demographics
NPI:1366468753
Name:TAZBAZ, NELLIE PETRONELLA (DDS)
Entity Type:Individual
Prefix:DR
First Name:NELLIE
Middle Name:PETRONELLA
Last Name:TAZBAZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3796 CLAIREMONT DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5916
Mailing Address - Country:US
Mailing Address - Phone:858-273-5788
Mailing Address - Fax:858-273-5337
Practice Address - Street 1:3796 CLAIREMONT DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5916
Practice Address - Country:US
Practice Address - Phone:858-273-5788
Practice Address - Fax:858-273-5337
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA453311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4533101OtherDENTI-CAL
CAB4533101OtherHEALTHY FAMILIES/DELTA