Healthcare Provider Details

I. General information

NPI: 1013527365
Provider Name (Legal Business Name): MARYIAM ELIZABETH BARKHO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2020
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 SOUTH MAIN STREET SUITE B
SANTA ANA CA
92701
US

IV. Provider business mailing address

3138 MANISTEE DR
COSTA MESA CA
92626-3124
US

V. Phone/Fax

Practice location:
  • Phone: 800-755-9771
  • Fax:
Mailing address:
  • Phone: 714-785-6512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number105001
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number105001
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: