Provider Demographics
NPI:1053201798
Name:KHOROUSHI, MARYAM
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:KHOROUSHI
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 1:4340 EAST JENSEN AVENUE,
Mailing Address - Street 2:FRESNO, CA
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93725
Mailing Address - Country:US
Mailing Address - Phone:800-492-4227
Mailing Address - Fax:559-646-6906
Practice Address - Street 1:4340 EAST JENSEN AVENUE, FRESNO, CA 93725
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93725
Practice Address - Country:US
Practice Address - Phone:800-492-4227
Practice Address - Fax:559-646-6906
Is Sole Proprietor?:No
Enumeration Date:2025-07-04
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112410122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program