Provider Demographics
NPI:1285788141
Name:RAZVI, MARIAM (DDS)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:RAZVI
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 1:3347 GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-2432
Mailing Address - Country:US
Mailing Address - Phone:317-490-4688
Mailing Address - Fax:317-291-2208
Practice Address - Street 1:3347 GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-2432
Practice Address - Country:US
Practice Address - Phone:317-490-4688
Practice Address - Fax:317-291-2208
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120089311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100125700AMedicaid