Provider Demographics
NPI:1992473862
Name:KEIKHOSRO-KIANI, MARYAM (DMD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:KEIKHOSRO-KIANI
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 1:1415 PIPELINE ROAD
Mailing Address - Street 2:
Mailing Address - City:COQUITLAM
Mailing Address - State:BRITISH COLUMBIA
Mailing Address - Zip Code:V3E 2X1
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10725 SE 256TH ST STE 1
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-8285
Practice Address - Country:US
Practice Address - Phone:602-551-5626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61204490122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist