MEDICARE: DR. MARYAM S TABATABAEI 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	122300000X	Dentist	28123	TX

General Provider Information

NPI Number	:	1821333881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARYAM S TABATABAEI DMD

Provider Business Mailing Address
First Line	:	2860 MICHELLE FL 2
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92606-1008
Country	:	US
Telephone Number	:	714-368-2084
Fax Number	:	714-508-6400

Provider Business Practice Location Address
First Line	:	5851 LONG PRAIRIE RD STE 101
Second Line	:
City	:	FLOWER MOUND
State	:	TX
Zip	:	75028-5636
Country	:	US
Telephone Number	:	972-539-7252
Fax Number	:	972-692-5144

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

Provider Enumeration Date	:	12/03/2012
Last Update Date	:	12/03/2012

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