Provider Demographics
NPI:1215357637
Name:ABBASI, MARYAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:ABBASI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 CHESTNUT HILL DR
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-2711
Mailing Address - Country:US
Mailing Address - Phone:650-862-6107
Mailing Address - Fax:
Practice Address - Street 1:82 CHESTNUT HILL DR
Practice Address - Street 2:
Practice Address - City:NEW PROVIDENCE
Practice Address - State:NJ
Practice Address - Zip Code:07974-2711
Practice Address - Country:US
Practice Address - Phone:650-862-6107
Practice Address - Fax:650-862-6107
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI025843001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program