Provider Demographics
NPI:1346775327
Name:ANDRE, ANYA LISHA (DMD)
Entity Type:Individual
Prefix:
First Name:ANYA
Middle Name:LISHA
Last Name:ANDRE
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 1:9245 RAINIER AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118
Mailing Address - Country:US
Mailing Address - Phone:206-548-3638
Mailing Address - Fax:
Practice Address - Street 1:9245 RAINIER AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118
Practice Address - Country:US
Practice Address - Phone:206-548-3638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2017-12-19
Deactivation Date:2017-11-29
Deactivation Code:
Reactivation Date:2017-12-19
Provider Licenses
StateLicense IDTaxonomies
390200000X
WARR60760772390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program