Provider Demographics
NPI:1497405161
Name:MARYA, TARANNUM
Entity Type:Individual
Prefix:
First Name:TARANNUM
Middle Name:
Last Name:MARYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BAYSIDE VILLAGE PL APT 402
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-1468
Mailing Address - Country:US
Mailing Address - Phone:415-827-5250
Mailing Address - Fax:
Practice Address - Street 1:2101 E 71ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-2143
Practice Address - Country:US
Practice Address - Phone:773-241-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist