Provider Demographics
NPI:1851753156
Name:MAHDAVI, MARYAM (DMD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:MAHDAVI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-3766
Mailing Address - Country:US
Mailing Address - Phone:617-909-6118
Mailing Address - Fax:
Practice Address - Street 1:978 ROCKAWAY AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-2136
Practice Address - Country:US
Practice Address - Phone:617-909-6118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-25
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY060887-011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty