Healthcare Provider Details

I. General information

NPI: 1497968697
Provider Name (Legal Business Name): MARYAM MICHELLE PEAROSE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26730 TOWNE CENTRE DR SUITE 106
FOOTHILL RANCH CA
92610-2842
US

IV. Provider business mailing address

26730 TOWNE CENTRE DR SUITE 106
FOOTHILL RANCH CA
92610-2842
US

V. Phone/Fax

Practice location:
  • Phone: 949-716-2800
  • Fax: 949-716-2900
Mailing address:
  • Phone: 949-716-2800
  • Fax: 949-716-2900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number51508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: