Provider Demographics
NPI:1700127321
Name:M. TAVALLAEI DMD INC
Entity Type:Organization
Organization Name:M. TAVALLAEI DMD INC
Other - Org Name:SMILE TIME DENTAL
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:916-984-4224
Mailing Address - Street 1:2260 E. BIDWELL STREET
Mailing Address - Street 2:SUITE 309
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630
Mailing Address - Country:US
Mailing Address - Phone:916-984-4224
Mailing Address - Fax:916-984-4248
Practice Address - Street 1:3433 ARDEN WAY
Practice Address - Street 2:SUITE B
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2018
Practice Address - Country:US
Practice Address - Phone:916-984-4224
Practice Address - Fax:916-984-4248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty