MEDICARE: MARYAM BAKHTIYARI, D.D.S PROFESSIONAL DENTAL CORP

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	332BC3200X	Customized Equipment (DME)

General Provider Information

NPI Number	:	1336925908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARYAM BAKHTIYARI, D.D.S PROFESSIONAL DENTAL CORP

Provider Business Mailing Address
First Line	:	1117 2ND ST
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-6834
Country	:	US
Telephone Number	:	310-372-6600
Fax Number	:	310-372-4290

Provider Business Practice Location Address
First Line	:	1117 2ND ST
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-6834
Country	:	US
Telephone Number	:	310-372-6600
Fax Number	:	310-372-4290

Authorized Official
Title or Position	:	INSURANCE BILLER
Name	:	AICHA BAYROUK
Credential	:
Telephone Number	:	310-372-6600

Provider Enumeration Date	:	09/07/2023
Last Update Date	:	09/07/2023

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