Provider Demographics
NPI:1013482868
Name:TAVAKOLI, MARK MAJID (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:MAJID
Last Name:TAVAKOLI
Suffix:
Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:310 N CIVIC DR APT 501
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-3694
Mailing Address - Country:US
Mailing Address - Phone:925-285-2125
Mailing Address - Fax:
Practice Address - Street 1:310 N CIVIC DR APT 501
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-3694
Practice Address - Country:US
Practice Address - Phone:925-285-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA395681223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty