Provider Demographics
NPI:1013579010
Name:ESMAILZADEGAN, JASMINE (DMD)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:ESMAILZADEGAN
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 1:200 S KIRKWOOD RD STE 90
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-4351
Mailing Address - Country:US
Mailing Address - Phone:314-858-1175
Mailing Address - Fax:
Practice Address - Street 1:200 S KIRKWOOD RD STE 90
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-4351
Practice Address - Country:US
Practice Address - Phone:314-858-1175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190224661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice