Provider Demographics
NPI:1073126058
Name:BARASATIAN, JODIE (DMD)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:BARASATIAN
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 1:3510 SCOTTS LN APT 3143
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1691
Mailing Address - Country:US
Mailing Address - Phone:215-391-6287
Mailing Address - Fax:
Practice Address - Street 1:310 N LANCASTER ST
Practice Address - Street 2:
Practice Address - City:JONESTOWN
Practice Address - State:PA
Practice Address - Zip Code:17038-8909
Practice Address - Country:US
Practice Address - Phone:717-865-5211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0428121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice