Provider Demographics
NPI:1205459500
Name:GHANEM, JASMINE A (DMD)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:A
Last Name:GHANEM
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 1:469 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-5430
Mailing Address - Country:US
Mailing Address - Phone:917-497-4337
Mailing Address - Fax:
Practice Address - Street 1:5800 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3702
Practice Address - Country:US
Practice Address - Phone:718-630-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0622811223P0221X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223P0221XDental ProvidersDentistPediatric Dentistry