MEDICARE: MARIAM GHAVAMIAN DMD, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1093917593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIAM GHAVAMIAN DMD, PC

Provider Business Mailing Address
First Line	:	1247 BEACON ST
Second Line	:
City	:	BROOKLINE
State	:	MA
Zip	:	02446-5273
Country	:	US
Telephone Number	:	617-738-0806
Fax Number	:	617-232-8933

Provider Business Practice Location Address
First Line	:	1247 BEACON ST
Second Line	:
City	:	BROOKLINE
State	:	MA
Zip	:	02446-5273
Country	:	US
Telephone Number	:	617-738-0806
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARIAM GHAVAMIAN
Credential	:	DMD, PC
Telephone Number	:	617-738-0806

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	08/22/2020

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