Provider Demographics
NPI:1275733263
Name:MARIAM GHAVAMIAN DMD PC
Entity Type:Organization
Organization Name:MARIAM GHAVAMIAN DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GHAVAMIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-738-0806
Mailing Address - Street 1:21 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446
Mailing Address - Country:US
Mailing Address - Phone:617-738-0806
Mailing Address - Fax:
Practice Address - Street 1:21 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446
Practice Address - Country:US
Practice Address - Phone:617-738-0806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA180121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty