Provider Demographics
NPI:1417322744
Name:YAZDIZADEH, MARYAM (DDS)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:YAZDIZADEH
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1559
Mailing Address - Country:US
Mailing Address - Phone:661-635-3050
Mailing Address - Fax:661-635-3070
Practice Address - Street 1:7800 NILES ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-4922
Practice Address - Country:US
Practice Address - Phone:661-328-4284
Practice Address - Fax:661-616-9980
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60460427122300000X
CA1000071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist