Provider Demographics
NPI:1134443732
Name:ROSTAMI, MARYAM (DMD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:ROSTAMI
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 1:207 GEORGE ST
Mailing Address - Street 2:APT 516
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3590
Mailing Address - Country:US
Mailing Address - Phone:857-756-5867
Mailing Address - Fax:
Practice Address - Street 1:483 MIDDLE TPKE W
Practice Address - Street 2:UNIT 309
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3863
Practice Address - Country:US
Practice Address - Phone:866-645-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0104011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice