MEDICARE: MARYAM KHAZAEIZADEH 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	33330	TX

General Provider Information

NPI Number	:	1427573617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYAM KHAZAEIZADEH DDS

Provider Business Mailing Address
First Line	:	3107 RICE BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-3051
Country	:	US
Telephone Number	:	281-468-4900
Fax Number	:

Provider Business Practice Location Address
First Line	:	3107 RICE BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-3051
Country	:	US
Telephone Number	:	281-468-4900
Fax Number	:

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

Provider Enumeration Date	:	08/08/2017
Last Update Date	:	08/08/2017

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