Provider Demographics
NPI:1073968103
Name:ANAYA, JOSE DE JESUS (DDS)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:DE JESUS
Last Name:ANAYA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4364 BONITA RD # 233
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CALLE MINA DE ORO #950
Practice Address - Street 2:COL. LOMAS DE CUCHUMA
Practice Address - City:TECATO
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:21447
Practice Address - Country:MX
Practice Address - Phone:01152665-654-5039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ1694007122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist