Provider Demographics
NPI:1992290456
Name:BAWANY, MARIAM (DMD)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:BAWANY
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 1:2061 PENNSBURY LN
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-6712
Mailing Address - Country:US
Mailing Address - Phone:773-946-2384
Mailing Address - Fax:
Practice Address - Street 1:320 E ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3172
Practice Address - Country:US
Practice Address - Phone:309-624-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031633122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist