Provider Demographics
NPI:1164831913
Name:MOARECHIPOUR, MARYAM
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:MOARECHIPOUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10314 LA GUARDIA CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-8824
Mailing Address - Country:US
Mailing Address - Phone:407-257-6787
Mailing Address - Fax:
Practice Address - Street 1:1013 LOCKWOOD BLVD STE 7
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-6001
Practice Address - Country:US
Practice Address - Phone:407-278-0934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20865122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist