Healthcare Provider Details

I. General information

NPI: 1578184024
Provider Name (Legal Business Name): MARIAM AZIM DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 ELMWOOD RD N
MARLTON NJ
08053-2373
US

IV. Provider business mailing address

74 LAFAYETTE MILLS RD
MANALAPAN NJ
07726-2840
US

V. Phone/Fax

Practice location:
  • Phone: 856-291-6888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02850800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number07120
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: