Provider Demographics
NPI:1891882114
Name:AMIDI, MARYAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:AMIDI
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 1:1100 SHARON PARK DR
Mailing Address - Street 2:APT# 24
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-7009
Mailing Address - Country:US
Mailing Address - Phone:650-380-8680
Mailing Address - Fax:650-988-6655
Practice Address - Street 1:1039 EL MONTE AVE
Practice Address - Street 2:SUITE # E
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-2370
Practice Address - Country:US
Practice Address - Phone:650-988-6500
Practice Address - Fax:650-988-6655
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA510401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice