Provider Demographics
NPI:1104436690
Name:GHORBANI, MARYAM (DDS)
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:GHORBANI
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:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92079-0564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 WATERSIDE PLZ APT 12B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-2636
Practice Address - Country:US
Practice Address - Phone:760-666-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-09
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105212122300000X
MO20240266981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Multi-Specialty