Provider Demographics
NPI:1336744093
Name:JASIM, ALI TAHSEEN
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:TAHSEEN
Last Name:JASIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10270 E TARON DR APT 230
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-8243
Mailing Address - Country:US
Mailing Address - Phone:619-201-5390
Mailing Address - Fax:
Practice Address - Street 1:853 PLUMAS ST
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-4010
Practice Address - Country:US
Practice Address - Phone:530-763-5595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105839122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist