Healthcare Provider Details

I. General information

NPI: 1780812313
Provider Name (Legal Business Name): JACQUELINE LEAH SADEGHIAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE LEAH ILLUMINATE

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 05/08/2024
Certification Date: 01/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 N LAKE DR
LEXINGTON SC
29072
US

IV. Provider business mailing address

203 N LAKE DR
LEXINGTON SC
29072-2833
US

V. Phone/Fax

Practice location:
  • Phone: 678-244-4871
  • Fax:
Mailing address:
  • Phone: 254-383-4559
  • Fax: 702-456-6160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9522
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9522
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: