Provider Demographics
NPI:1306874029
Name:MOGHADAM, MARYAM (DDS)
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:MOGHADAM
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 1:22778 E POCO CALLE
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-1449
Mailing Address - Country:US
Mailing Address - Phone:847-848-6339
Mailing Address - Fax:
Practice Address - Street 1:234 RIDGE AVE
Practice Address - Street 2:#1
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3349
Practice Address - Country:US
Practice Address - Phone:847-864-5491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190258361223G0001X
AZD010262122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice