Provider Demographics
NPI:1316404387
Name:GOTZ, ANITA LEORAH (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANITA
Middle Name:LEORAH
Last Name:GOTZ
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 1:510 E 85TH ST APT 6H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-7435
Mailing Address - Country:US
Mailing Address - Phone:267-912-7220
Mailing Address - Fax:
Practice Address - Street 1:1053 BLOOMFIELD AVE STE 14
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-2120
Practice Address - Country:US
Practice Address - Phone:973-471-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ070891223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program