Provider Demographics
NPI:1497523732
Name:TAIS TREVELIN DMD INC
Entity Type:Organization
Organization Name:TAIS TREVELIN DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAIS TREVELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWRY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:509-508-7395
Mailing Address - Street 1:12378 POWAY RD STE B
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-4242
Mailing Address - Country:US
Mailing Address - Phone:858-679-8918
Mailing Address - Fax:858-679-6993
Practice Address - Street 1:12378 POWAY RD STE B
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-4242
Practice Address - Country:US
Practice Address - Phone:858-679-8918
Practice Address - Fax:858-679-6993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty