Provider Demographics
NPI:1578101630
Name:KHALILI, MARYAM (DDS-PROSTHODONTIST)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:KHALILI
Suffix:
Gender:F
Credentials:DDS-PROSTHODONTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 RAYMOND BLVD APT 11C
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-4120
Mailing Address - Country:US
Mailing Address - Phone:773-807-9934
Mailing Address - Fax:
Practice Address - Street 1:3223 N BROAD ST OFC 314
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5007
Practice Address - Country:US
Practice Address - Phone:773-807-9934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34590122300000X
VA0401416303122300000X
PARFD0000331223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist