=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992040760
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIAM GAWARGI D.M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2012
-----------------------------------------------------
Last Update Date | 09/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 NORTHAMPTON ST STE 102
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18042-4152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-527-0272
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 635 E BROAD ST
-----------------------------------------------------
City | BETHLEHEM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18018-6332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI02510000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS042603
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------