Provider Demographics
NPI:1396838694
Name:TABASSIAN, MARYAM (DDS)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:TABASSIAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 DULUTH HWY
Mailing Address - Street 2:STE E2
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043
Mailing Address - Country:US
Mailing Address - Phone:678-209-2273
Mailing Address - Fax:678-209-2275
Practice Address - Street 1:911 DULUTH HWY
Practice Address - Street 2:STE E2
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043
Practice Address - Country:US
Practice Address - Phone:678-209-2273
Practice Address - Fax:678-209-2275
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO12412122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist