MEDICARE: MARIAM RASSAM DDS

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	108154	CA

General Provider Information

NPI Number	:	1316662778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAM RASSAM DDS

Provider Business Mailing Address
First Line	:	1509 FAIR GLEN RD
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92019-3715
Country	:	US
Telephone Number	:	619-456-3979
Fax Number	:

Provider Business Practice Location Address
First Line	:	7484 UNIVERSITY AVE
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91942-6063
Country	:	US
Telephone Number	:	619-462-2272
Fax Number	:

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

Provider Enumeration Date	:	10/07/2022
Last Update Date	:	09/15/2023

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