Provider Demographics
NPI:1235216342
Name:MANOUCHEHRI, MARYAM (DMD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:MANOUCHEHRI
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 1:1130 BLACKWOOD CLEMENTON RD
Mailing Address - Street 2:
Mailing Address - City:PINE HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-6965
Mailing Address - Country:US
Mailing Address - Phone:856-627-2400
Mailing Address - Fax:856-783-2798
Practice Address - Street 1:1130 BLACKWOOD CLEMENTON RD
Practice Address - Street 2:
Practice Address - City:PINE HILL
Practice Address - State:NJ
Practice Address - Zip Code:08021-6965
Practice Address - Country:US
Practice Address - Phone:856-627-2400
Practice Address - Fax:856-783-2798
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ206911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice