Provider Demographics
NPI:1407049810
Name:KISHTA-DERANI, MARYAM RUBY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:RUBY
Last Name:KISHTA-DERANI
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 1:6633 WESTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1371
Mailing Address - Country:US
Mailing Address - Phone:248-408-3136
Mailing Address - Fax:
Practice Address - Street 1:2815 S PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3496
Practice Address - Country:US
Practice Address - Phone:517-272-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019672122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist