MEDICARE: DR. MARYAM AMIDI 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	51040	CA

General Provider Information

NPI Number	:	1891882114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARYAM AMIDI DDS

Provider Business Mailing Address
First Line	:	1100 SHARON PARK DR
Second Line	:	APT# 24
City	:	MENLO PARK
State	:	CA
Zip	:	94025-7009
Country	:	US
Telephone Number	:	650-380-8680
Fax Number	:	650-988-6655

Provider Business Practice Location Address
First Line	:	1039 EL MONTE AVE
Second Line	:	SUITE # E
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94040-2370
Country	:	US
Telephone Number	:	650-988-6500
Fax Number	:	650-988-6655

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

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	07/08/2007

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