Provider Demographics
NPI:1235200205
Name:FALLAHZADEH, MARIAM SUSANNE (DMD)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:SUSANNE
Last Name:FALLAHZADEH
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 1:4223A LEXINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:KY
Mailing Address - Zip Code:40361
Mailing Address - Country:US
Mailing Address - Phone:859-988-0308
Mailing Address - Fax:859-988-0310
Practice Address - Street 1:4223A LEXINGTON ROAD
Practice Address - Street 2:BOURBON FAMILY DENTISTRY PLLC
Practice Address - City:PARIS
Practice Address - State:KY
Practice Address - Zip Code:40361
Practice Address - Country:US
Practice Address - Phone:859-988-0308
Practice Address - Fax:859-988-0310
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY77701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice