Provider Demographics
NPI:1497836803
Name:MARYAM GHASEMYEH DDS INCORPORATED
Entity Type:Organization
Organization Name:MARYAM GHASEMYEH DDS INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GHASEMYEH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-547-9411
Mailing Address - Street 1:PO BOX 10175
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92711-0175
Mailing Address - Country:US
Mailing Address - Phone:714-547-9411
Mailing Address - Fax:
Practice Address - Street 1:801 N TUSTIN AVE
Practice Address - Street 2:SUITE #400
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3612
Practice Address - Country:US
Practice Address - Phone:714-547-9411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS36152122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADDS36152OtherCA DENTAL LICENSE