Provider Demographics
NPI:1386189116
Name:SHAFAGH, JASMINE ROXANA (DMD)
Entity type:Individual
Prefix:DR
First Name:JASMINE
Middle Name:ROXANA
Last Name:SHAFAGH
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 1:100 S EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-3202
Mailing Address - Country:US
Mailing Address - Phone:610-446-6688
Mailing Address - Fax:
Practice Address - Street 1:100 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-3202
Practice Address - Country:US
Practice Address - Phone:610-446-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-03
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041117122300000X
FLDN22385122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist