Basic Information
| Provider Information | |||||||||
| NPI: | 1093759987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHODDUSI-TABARSI | ||||||||
| FirstName: | FARIDEH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 JOHN JONES RD | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956169701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307581510 | ||||||||
| FaxNumber: | 5307581510 | ||||||||
| Practice Location | |||||||||
| Address1: | 2051 JOHN JONES RD | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307581510 | ||||||||
| FaxNumber: | 5307581510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 12/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 39640 | CA | Y | Dental Providers | Dentist |
No ID Information.