Provider Demographics
NPI:1487115507
Name:TAVAKOLI, PAYMAAN CHRISTOPHER (DDS)
Entity type:Individual
Prefix:DR
First Name:PAYMAAN
Middle Name:CHRISTOPHER
Last Name:TAVAKOLI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 LANCASTER AVE APT 209
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19611-1670
Mailing Address - Country:US
Mailing Address - Phone:301-928-1578
Mailing Address - Fax:
Practice Address - Street 1:7425 ARLINGTON RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-5321
Practice Address - Country:US
Practice Address - Phone:301-652-2123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD167151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty