Provider Demographics
NPI:1235667247
Name:BAK, ANNA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:
Last Name:BAK
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 1:90 S RIDGE ST STE LL-9A
Mailing Address - Street 2:
Mailing Address - City:RYE BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:10573-2836
Mailing Address - Country:US
Mailing Address - Phone:914-925-1099
Mailing Address - Fax:
Practice Address - Street 1:90 S RIDGE ST STE LL-9A
Practice Address - Street 2:
Practice Address - City:RYE BROOK
Practice Address - State:NY
Practice Address - Zip Code:10573-2836
Practice Address - Country:US
Practice Address - Phone:914-925-1099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-03
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0606771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program