Provider Demographics
NPI:1447470885
Name:BAKHTIYARI, MARYAM (DDS)
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:BAKHTIYARI
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 1:1117 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6834
Mailing Address - Country:US
Mailing Address - Phone:310-372-6600
Mailing Address - Fax:310-372-4290
Practice Address - Street 1:1117 2ND ST
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-6834
Practice Address - Country:US
Practice Address - Phone:310-372-6600
Practice Address - Fax:310-372-4290
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA413471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice