Provider Demographics
NPI:1093928632
Name:EKHTIAR, MARYAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:EKHTIAR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31897 DEL OBISPO ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3207
Mailing Address - Country:US
Mailing Address - Phone:949-487-0284
Mailing Address - Fax:949-487-0294
Practice Address - Street 1:31897 DEL OBISPO ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3207
Practice Address - Country:US
Practice Address - Phone:949-487-0284
Practice Address - Fax:949-487-0294
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50905122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist