Provider Demographics
NPI:1558640185
Name:GOLSHANI, MARYAM MOGHADAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:MOGHADAM
Last Name:GOLSHANI
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 1:730 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3604
Mailing Address - Country:US
Mailing Address - Phone:630-696-1498
Mailing Address - Fax:
Practice Address - Street 1:522 W CHESTNUT ST STE 1C
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3172
Practice Address - Country:US
Practice Address - Phone:630-655-3522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-14
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100763122300000X
IL0190287641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentist