Healthcare Provider Details

I. General information

NPI: 1740499797
Provider Name (Legal Business Name): MARIAM VAZIRI D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 BEECHWOOD RD SUITE 2
SUMMIT NJ
07901-2532
US

IV. Provider business mailing address

28 BEECHWOOD RD SUITE 2
SUMMIT NJ
07901-2532
US

V. Phone/Fax

Practice location:
  • Phone: 978-692-6326
  • Fax: 908-737-1353
Mailing address:
  • Phone: 617-794-0889
  • Fax: 908-737-1353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20045
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02098000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: