Provider Demographics
NPI:1922261882
Name:TAVALLAEI, D.M.D., CORPORATION
Entity Type:Organization
Organization Name:TAVALLAEI, D.M.D., CORPORATION
Other - Org Name:MAKE A SMILE
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:916-271-3737
Mailing Address - Street 1:2260 E BIDWELL ST # 314
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:916-271-3737
Mailing Address - Fax:
Practice Address - Street 1:9184 E STOCKTON BLVD STE A
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-9510
Practice Address - Country:US
Practice Address - Phone:916-271-3737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty