Provider Demographics
NPI:1457735342
Name:GUZMAN, JASMIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASMIN
Middle Name:
Last Name:GUZMAN
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 1:3212 S LEAVITT ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-6017
Mailing Address - Country:US
Mailing Address - Phone:773-936-2227
Mailing Address - Fax:
Practice Address - Street 1:3860 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2460
Practice Address - Country:US
Practice Address - Phone:872-588-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030256122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019030256OtherSTATE LICENSE
IL319019530OtherCDS
IL728780Medicaid
ILFG5410369OtherDEA