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General NPI Number Information
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NPI Number | 1104436690
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Entity Type | Individual
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Provider Name | MARYAM GHORBANI DDS
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Gender | Female
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Dates
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Enumeration Date | 08/09/2020
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Last Update Date | 12/13/2024
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Provider Practice Location Address
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Address Line | 40 WATERSIDE PLZ APT 12B
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City | NEW YORK
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State | NY
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Zip | 10010-2636
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Country | US
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Telephone | 760-666-5066
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 564
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City | SAN MARCOS
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State | CA
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Zip | 92079-0564
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 105212
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2024026698
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License Number State | MO
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