Provider Demographics
NPI:1023538253
Name:IVANOVA, ANNA VICTOROVNA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:VICTOROVNA
Last Name:IVANOVA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:INNA
Other - Middle Name:
Other - Last Name:IVANOVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:413 ALFRED ST STE 101
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-3742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:413 ALFRED ST STE 101
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-3742
Practice Address - Country:US
Practice Address - Phone:207-569-8167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN45641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice