Provider Demographics
NPI:1477267490
Name:AL SHAKARCHI, MARIAM ALAA
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:ALAA
Last Name:AL SHAKARCHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIAM
Other - Middle Name:ALAA
Other - Last Name:AL SHAKARCHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 W LEXINGTON AVE UNIT 579
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92022-5224
Mailing Address - Country:US
Mailing Address - Phone:619-751-0799
Mailing Address - Fax:
Practice Address - Street 1:1357 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-1934
Practice Address - Country:US
Practice Address - Phone:323-835-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108500122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist