Provider Demographics
NPI:1689873226
Name:NASSIRI, MARYAM (DDS)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:NASSIRI
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 1:5165 LONE TREE WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8484
Mailing Address - Country:US
Mailing Address - Phone:925-756-1200
Mailing Address - Fax:925-756-1202
Practice Address - Street 1:5165 LONE TREE WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8484
Practice Address - Country:US
Practice Address - Phone:925-756-1200
Practice Address - Fax:925-756-1202
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA503291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice