Provider Demographics
NPI:1194369801
Name:MOSPANOVA, ANASTASIA (DDS)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:
Last Name:MOSPANOVA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1965 E 15TH AVE APT 331
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-3006
Mailing Address - Country:US
Mailing Address - Phone:650-691-3606
Mailing Address - Fax:
Practice Address - Street 1:1740 W 17TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3619
Practice Address - Country:US
Practice Address - Phone:458-210-3543
Practice Address - Fax:541-516-4037
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11327122300000X
IL019032426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty