Healthcare Provider Details

I. General information

NPI: 1437993011
Provider Name (Legal Business Name): MARYAM LINA WASEEM DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17365 US HIGHWAY 441 FL 32757
MOUNT DORA FL
32757-6715
US

IV. Provider business mailing address

7600 MAJORCA PL APT 5041
ORLANDO FL
32819-5561
US

V. Phone/Fax

Practice location:
  • Phone: 352-270-3015
  • Fax:
Mailing address:
  • Phone: 954-707-7762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN29167
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: