Provider Demographics
NPI:1245654508
Name:SEDAGHATPOUR, JASMINE (DDS)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:SEDAGHATPOUR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3377 LONG BEACH RD
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5063
Mailing Address - Country:US
Mailing Address - Phone:516-766-0732
Mailing Address - Fax:
Practice Address - Street 1:3377 LONG BEACH RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-5063
Practice Address - Country:US
Practice Address - Phone:516-766-0732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY058049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program