Provider Demographics
NPI:1003507211
Name:GALLUP, JASMIN ALAYSHA
Entity Type:Individual
Prefix:
First Name:JASMIN
Middle Name:ALAYSHA
Last Name:GALLUP
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 1:1 GREYROCK PL APT 3109
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901-3139
Mailing Address - Country:US
Mailing Address - Phone:860-216-8801
Mailing Address - Fax:
Practice Address - Street 1:4 DEARFIELD DR
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831-5351
Practice Address - Country:US
Practice Address - Phone:203-422-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8724124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist