Provider Demographics
NPI:1073232625
Name:FANAEIAN, ANISA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANISA
Middle Name:
Last Name:FANAEIAN
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 1:117 COFFEE TREE CT
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-2428
Mailing Address - Country:US
Mailing Address - Phone:404-343-9462
Mailing Address - Fax:
Practice Address - Street 1:117 COFFEE TREE CT
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-2428
Practice Address - Country:US
Practice Address - Phone:404-343-9462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401418091122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist