Provider Demographics
NPI:1033347752
Name:JASTI, SUSMITHA (DMD)
Entity Type:Individual
Prefix:MRS
First Name:SUSMITHA
Middle Name:
Last Name:JASTI
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 1:4801 WILSON ROAD, STE 200
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396
Mailing Address - Country:US
Mailing Address - Phone:281-441-1065
Mailing Address - Fax:
Practice Address - Street 1:4801 WILSON ROAD, STE 200
Practice Address - Street 2:
Practice Address - City:HUMBLE,
Practice Address - State:TX
Practice Address - Zip Code:77396
Practice Address - Country:US
Practice Address - Phone:281-441-1065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855163122300000X
TX26353122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist