Provider Demographics
NPI:1396908943
Name:TAYEBATY, FARDAD (DMD)
Entity type:Individual
Prefix:
First Name:FARDAD
Middle Name:
Last Name:TAYEBATY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 S GREEN VALLEY RD STE 7
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-3077
Mailing Address - Country:US
Mailing Address - Phone:617-875-3211
Mailing Address - Fax:
Practice Address - Street 1:390 S GREEN VALLEY RD STE 7
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-3077
Practice Address - Country:US
Practice Address - Phone:617-875-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1024352001223G0001X
CA1009121223E0200X
NJ22DI024352001223E0200X
NY0558151223E0200X
MA222921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice