1386159879 NPI number — TAVALLAEI, D.M.D., CORPORATION

Table of content: (NPI 1386159879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386159879 NPI number — TAVALLAEI, D.M.D., CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAVALLAEI, D.M.D., CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386159879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2260 E BIDWELL ST STE 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOLSOM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95630-3555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9130 ALCOSTA BLVD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN RAMON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94583-3847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-402-4141
Provider Business Practice Location Address Fax Number:
916-983-9012
Provider Enumeration Date:
12/06/2017

Additional Information

Authorized Official

Authorized Official Last Name:
CASTILLO
Authorized Official First Name:
MEGAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OPERATIONS MANAGER
Authorized Official Telephone Number:
916-781-6550

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  1700020026 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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