Healthcare Provider Details

I. General information

NPI: 1306779533
Provider Name (Legal Business Name): MARIAM SHERIF AWAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2026
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 CHURCH RD W
SOUTHAVEN MS
38671-9611
US

IV. Provider business mailing address

1709 OLIVE CIR
NASHVILLE TN
37217-3851
US

V. Phone/Fax

Practice location:
  • Phone: 662-253-8027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number112724
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: