Provider Demographics
NPI:1235202979
Name:GHAVAMIAN, MARIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIAM
Middle Name:
Last Name:GHAVAMIAN
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 1:1247 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5273
Mailing Address - Country:US
Mailing Address - Phone:617-738-0806
Mailing Address - Fax:617-232-8933
Practice Address - Street 1:1247 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5273
Practice Address - Country:US
Practice Address - Phone:617-738-0806
Practice Address - Fax:617-232-8933
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA180121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics