Provider Demographics
NPI:1013427285
Name:MOHAMMADVALI SAMANI, MARYAM (DMD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:MOHAMMADVALI SAMANI
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 1:5 LAKESHORE CTR UNIT 1251
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-1084
Mailing Address - Country:US
Mailing Address - Phone:617-909-2300
Mailing Address - Fax:
Practice Address - Street 1:292 CHAUNCY ST # 150
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048-1203
Practice Address - Country:US
Practice Address - Phone:508-406-9592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2023-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18577601223E0200X
MADN18577601223G0001X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice