Provider Demographics
NPI:1033873203
Name:SEGHATOLESLAMI, SOGOL (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:SOGOL
Middle Name:
Last Name:SEGHATOLESLAMI
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 N CENTER PKWY APT F201
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-8224
Mailing Address - Country:US
Mailing Address - Phone:949-540-3871
Mailing Address - Fax:
Practice Address - Street 1:8305 W QUINAULT AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1138
Practice Address - Country:US
Practice Address - Phone:509-628-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE611872041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics