MEDICARE: MARYAM MANOUCHEHRI DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	20691	NJ

General Provider Information

NPI Number	:	1235216342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYAM MANOUCHEHRI DMD

Provider Business Mailing Address
First Line	:	1130 BLACKWOOD CLEMENTON RD
Second Line	:
City	:	PINE HILL
State	:	NJ
Zip	:	08021-6965
Country	:	US
Telephone Number	:	856-627-2400
Fax Number	:	856-783-2798

Provider Business Practice Location Address
First Line	:	1130 BLACKWOOD CLEMENTON RD
Second Line	:
City	:	PINE HILL
State	:	NJ
Zip	:	08021-6965
Country	:	US
Telephone Number	:	856-627-2400
Fax Number	:	856-783-2798

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	06/14/2010

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