Provider Demographics
NPI:1619193521
Name:FATEHI, JALAL (DDS)
Entity Type:Individual
Prefix:
First Name:JALAL
Middle Name:
Last Name:FATEHI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 PHEASANT RUN
Mailing Address - Street 2:
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-1703
Mailing Address - Country:US
Mailing Address - Phone:201-406-4065
Mailing Address - Fax:516-629-6107
Practice Address - Street 1:22 PHEASANT RUN
Practice Address - Street 2:
Practice Address - City:OLD WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11568-1703
Practice Address - Country:US
Practice Address - Phone:516-484-2959
Practice Address - Fax:516-484-2154
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01985000204E00000X
NY046724204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01683834Medicaid
NJ0457841Medicaid