Provider Demographics
NPI:1821333881
Name:TABATABAEI, MARYAM S (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:S
Last Name:TABATABAEI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2860 MICHELLE FL 2
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1008
Mailing Address - Country:US
Mailing Address - Phone:714-368-2084
Mailing Address - Fax:714-508-6400
Practice Address - Street 1:5851 LONG PRAIRIE RD STE 101
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-5636
Practice Address - Country:US
Practice Address - Phone:972-539-7252
Practice Address - Fax:972-692-5144
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28123122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist