=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992510903
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELAF JASSOMA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2025
-----------------------------------------------------
Last Update Date | 02/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 INDEPENDENCE CIR STE 1A
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23455-6405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-490-3111
-----------------------------------------------------
Fax | 757-499-8768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5136 EDON HALL LN
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23464-6217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-333-7385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 0401419255
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------