Provider Demographics
NPI:1982037420
Name:FARNOOSH TABESH DDS INC
Entity Type:Organization
Organization Name:FARNOOSH TABESH DDS INC
Other - Org Name:TOLUCA LAKE COSMETIC DENTSITY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FARNOOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:TABESH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-928-8336
Mailing Address - Street 1:10724 RIVERSIDE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2313
Mailing Address - Country:US
Mailing Address - Phone:818-985-5777
Mailing Address - Fax:
Practice Address - Street 1:10724 RIVERSIDE DR
Practice Address - Street 2:SUITE A
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-2313
Practice Address - Country:US
Practice Address - Phone:818-985-5777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57822122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty