Provider Demographics
NPI:1447614599
Name:ABDOSSALEHI, ASSAL
Entity Type:Individual
Prefix:
First Name:ASSAL
Middle Name:
Last Name:ABDOSSALEHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 PELHAM PKWY S
Mailing Address - Street 2:BUILDING #1 SUITE 3NE1
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 W OLIVE AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506
Practice Address - Country:US
Practice Address - Phone:718-918-3419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1027541223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry