Healthcare Provider Details

I. General information

NPI: 1982586780
Provider Name (Legal Business Name): MRS. MARYAM NAKISA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2025
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17721 NORWALK BLVD
ARTESIA CA
90701-4355
US

IV. Provider business mailing address

17721 NORWALK BLVD UNIT 7
ARTESIA CA
90701-4356
US

V. Phone/Fax

Practice location:
  • Phone: 562-410-3544
  • Fax:
Mailing address:
  • Phone: 562-410-3544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113297
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: