Provider Demographics
NPI:1326239773
Name:DERMAWAN, JASMINE L (DMD)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:L
Last Name:DERMAWAN
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 1:2335 AMERICAN RIVER DR STE 307
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-7088
Mailing Address - Country:US
Mailing Address - Phone:916-929-0331
Mailing Address - Fax:
Practice Address - Street 1:8231 E STOCKTON BLVD STE D
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95828-8202
Practice Address - Country:US
Practice Address - Phone:916-368-3080
Practice Address - Fax:916-405-6551
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA95591223G0001X
CA577111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1301071Medicaid