Provider Demographics
NPI:1578724928
Name:M. TAVALLAEI, DMD,INC.
Entity Type:Organization
Organization Name:M. TAVALLAEI, DMD,INC.
Other - Org Name:SMILE TIME DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVALLAEI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:916-984-4224
Mailing Address - Street 1:2260 E BIDWELL ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3463
Mailing Address - Country:US
Mailing Address - Phone:916-984-4224
Mailing Address - Fax:916-984-4248
Practice Address - Street 1:2260 E BIDWELL ST
Practice Address - Street 2:SUITE 110
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3463
Practice Address - Country:US
Practice Address - Phone:916-984-4224
Practice Address - Fax:916-984-4248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA480361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty