Provider Demographics
NPI:1760044366
Name:TABANFAR, MATTHEW
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:TABANFAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 NOGALES DR
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-5120
Mailing Address - Country:US
Mailing Address - Phone:818-383-6050
Mailing Address - Fax:
Practice Address - Street 1:2225 E GARVEY AVE N
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-1500
Practice Address - Country:US
Practice Address - Phone:626-412-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103913122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist