Provider Demographics
NPI:1255707774
Name:MARYAM BANGASH DDS HOLDINGS PLLC
Entity type:Organization
Organization Name:MARYAM BANGASH DDS HOLDINGS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-454-6000
Mailing Address - Street 1:24185 US HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33859-7819
Mailing Address - Country:US
Mailing Address - Phone:863-676-6200
Mailing Address - Fax:863-679-2561
Practice Address - Street 1:24185 US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33859-7819
Practice Address - Country:US
Practice Address - Phone:863-676-6200
Practice Address - Fax:863-679-2561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN202721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty