Provider Demographics
NPI:1063930972
Name:FAZAL, MARYAM (DMD)
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:FAZAL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9226 GREENVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-7151
Mailing Address - Country:US
Mailing Address - Phone:214-336-3361
Mailing Address - Fax:
Practice Address - Street 1:3220 GUS THOMASSON RD
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4057
Practice Address - Country:US
Practice Address - Phone:817-222-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX328731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice