Provider Demographics
NPI:1619630480
Name:DASHTI, SEPI
Entity Type:Individual
Prefix:
First Name:SEPI
Middle Name:
Last Name:DASHTI
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 1:205 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3297
Mailing Address - Country:US
Mailing Address - Phone:312-477-1309
Mailing Address - Fax:
Practice Address - Street 1:338 S GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-4850
Practice Address - Country:US
Practice Address - Phone:847-336-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0331661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice