Provider Demographics
NPI:1124644844
Name:MOGHTADER, MARYAM (DMD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:MOGHTADER
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 1:20 HARRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01701-2642
Mailing Address - Country:US
Mailing Address - Phone:860-978-3186
Mailing Address - Fax:
Practice Address - Street 1:480 BOSTON RD UNIT 114
Practice Address - Street 2:
Practice Address - City:BILLERICA
Practice Address - State:MA
Practice Address - Zip Code:01821-2707
Practice Address - Country:US
Practice Address - Phone:978-330-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858667122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist