Provider Demographics
NPI:1871640870
Name:AVIN, MARYAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:AVIN
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 1:19366 DIAMOND LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-6574
Mailing Address - Country:US
Mailing Address - Phone:703-687-3255
Mailing Address - Fax:703-687-3246
Practice Address - Street 1:19366 DIAMOND LAKE DR
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-6574
Practice Address - Country:US
Practice Address - Phone:703-687-3255
Practice Address - Fax:703-687-3246
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014100651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice