Provider Demographics
NPI:1063145977
Name:ATISHA, MARIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:MARIAM
Middle Name:
Last Name:ATISHA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4144 MEADOW WAY
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1214
Mailing Address - Country:US
Mailing Address - Phone:248-764-8309
Mailing Address - Fax:
Practice Address - Street 1:33428 FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-2860
Practice Address - Country:US
Practice Address - Phone:734-427-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016014791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice