Provider Demographics
NPI:1982589222
Name:MOHAMADI, MARYAM
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:MOHAMADI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1889 VICENTE DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-6856
Mailing Address - Country:US
Mailing Address - Phone:805-215-4703
Mailing Address - Fax:
Practice Address - Street 1:3870 BROAD ST STE 1
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7172
Practice Address - Country:US
Practice Address - Phone:805-309-0467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1121851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice