Provider Demographics
NPI:1750614541
Name:M. TAVALLAEI, DMD, INC.
Entity type:Organization
Organization Name:M. TAVALLAEI, DMD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:916-984-4224
Mailing Address - Street 1:6000 FAIRWAY DR
Mailing Address - Street 2:SUITE 8B
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-4244
Mailing Address - Country:US
Mailing Address - Phone:916-984-4224
Mailing Address - Fax:916-984-4248
Practice Address - Street 1:6000 FAIRWAY DR
Practice Address - Street 2:SUITE 8B
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-4244
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:2009-09-10
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty