Provider Demographics
NPI:1740795657
Name:TAVALLAEI, D.M.D., CORPORATION
Entity Type:Organization
Organization Name:TAVALLAEI, D.M.D., CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-781-6550
Mailing Address - Street 1:2260 E BIDWELL ST # 311
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3555
Mailing Address - Country:US
Mailing Address - Phone:916-781-6550
Mailing Address - Fax:
Practice Address - Street 1:1955 W TEXAS ST STE 2A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4462
Practice Address - Country:US
Practice Address - Phone:916-707-7973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-14
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA480361223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty