Provider Demographics
NPI:1427573617
Name:KHAZAEIZADEH, MARYAM (DDS)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:KHAZAEIZADEH
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 1:3107 RICE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-3051
Mailing Address - Country:US
Mailing Address - Phone:281-468-4900
Mailing Address - Fax:
Practice Address - Street 1:3107 RICE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-3051
Practice Address - Country:US
Practice Address - Phone:281-468-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX333301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice