Provider Demographics
NPI:1992008098
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:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVALLAEI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:916-374-7711
Mailing Address - Street 1:3433 ARDEN WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3433 ARDEN WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2018
Practice Address - Country:US
Practice Address - Phone:916-374-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-10
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA480361223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty