Provider Demographics
NPI:1912642901
Name:TAVOUSSI, GILDA VAFA (DMD)
Entity Type:Individual
Prefix:DR
First Name:GILDA
Middle Name:VAFA
Last Name:TAVOUSSI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 MONARCH BAY DR
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-3438
Mailing Address - Country:US
Mailing Address - Phone:714-608-5573
Mailing Address - Fax:
Practice Address - Street 1:9209 COLIMA RD STE 2300
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90605-1817
Practice Address - Country:US
Practice Address - Phone:714-596-2660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44101122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty