Provider Demographics
NPI:1578253324
Name:TAVASOLI, ALEX (MS, DMD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:TAVASOLI
Suffix:
Gender:M
Credentials:MS, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35168 BLACKBURN DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560
Mailing Address - Country:US
Mailing Address - Phone:650-451-2035
Mailing Address - Fax:
Practice Address - Street 1:35168 BLACKBURN DRIVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560
Practice Address - Country:US
Practice Address - Phone:650-451-2035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034424122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program