Provider Demographics
NPI:1467781443
Name:REZAIE, MARYAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:REZAIE
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 1:4900 MARKET PLACE RD FL 32504
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8985
Mailing Address - Country:US
Mailing Address - Phone:850-477-1089
Mailing Address - Fax:
Practice Address - Street 1:4900 MARKET PLACE RD FL 32504
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504
Practice Address - Country:US
Practice Address - Phone:850-477-1089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-21
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN188551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics