Provider Demographics
NPI:1689306482
Name:JALALIAN, BAHAR
Entity type:Individual
Prefix:MISS
First Name:BAHAR
Middle Name:
Last Name:JALALIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 BENJAMIN H HILL DR SW
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-8694
Mailing Address - Country:US
Mailing Address - Phone:229-423-9471
Mailing Address - Fax:
Practice Address - Street 1:320 BENJAMIN H HILL DR SW
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-8694
Practice Address - Country:US
Practice Address - Phone:229-423-9471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1226971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice