Provider Demographics
NPI:1861653792
Name:TADHAMALOO DENTAL CORPORATION
Entity Type:Organization
Organization Name:TADHAMALOO DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUZAIFA
Authorized Official - Middle Name:HATIMALI
Authorized Official - Last Name:MALOO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-369-3344
Mailing Address - Street 1:5696 MISSION BLVD
Mailing Address - Street 2:5696 MISSION BLVD
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-4404
Mailing Address - Country:US
Mailing Address - Phone:951-369-3344
Mailing Address - Fax:951-369-4041
Practice Address - Street 1:5696 MISSION BLVD
Practice Address - Street 2:5696 MISSION BLVD
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-4404
Practice Address - Country:US
Practice Address - Phone:951-369-3344
Practice Address - Fax:951-369-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA493721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1871661652OtherNATIONAL PROVIDER IDENTIFIER
CA1891801825OtherNATIONAL PROVIDER IDENTIFIER