Provider Demographics
NPI:1548330194
Name:AZADI, MARYAM HOSSEINALI (DMD)
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:HOSSEINALI
Last Name:AZADI
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 1:27540 DETROIT RD 203
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2299
Mailing Address - Country:US
Mailing Address - Phone:440-835-1611
Mailing Address - Fax:440-892-1622
Practice Address - Street 1:4258 BELDEN VILLAGE MALL
Practice Address - Street 2:SPACE FC-17
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2504
Practice Address - Country:US
Practice Address - Phone:330-492-4250
Practice Address - Fax:330-492-4255
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2015-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0222471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2618877Medicaid