Provider Demographics
NPI:1013527365
Name:BARKHO, MARYIAM ELIZABETH
Entity Type:Individual
Prefix:
First Name:MARYIAM
Middle Name:ELIZABETH
Last Name:BARKHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3138 MANISTEE DR
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3124
Mailing Address - Country:US
Mailing Address - Phone:714-785-6512
Mailing Address - Fax:
Practice Address - Street 1:809 SOUTH MAIN STREET SUITE B
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701
Practice Address - Country:US
Practice Address - Phone:800-755-9771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1050011223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice