=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710544051
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARYAM HAMDAN DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2019
-----------------------------------------------------
Last Update Date | 02/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 E BETHANY HOME RD STE A132
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85012-1276
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-900-1857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 E BETHANY HOME RD STE A132
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85012-1276
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-900-1857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D010647
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN1858267
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------