Provider Demographics
NPI:1811107725
Name:KHAKPOUR, MARYAM EZADI
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:EZADI
Last Name:KHAKPOUR
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARYAM
Other - Middle Name:
Other - Last Name:EZADI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1277 MONTEGO
Mailing Address - Street 2:APT #44
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2840
Mailing Address - Country:US
Mailing Address - Phone:925-324-8043
Mailing Address - Fax:925-465-5508
Practice Address - Street 1:1844 SAN MIGUEL DR
Practice Address - Street 2:SUITE # 206
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-4962
Practice Address - Country:US
Practice Address - Phone:925-279-3326
Practice Address - Fax:925-279-2270
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA556251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice