Provider Demographics
NPI:1467221531
Name:ANIS, M SHADI
Entity Type:Individual
Prefix:
First Name:M SHADI
Middle Name:
Last Name:ANIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 N LINCOLN WAY STE 40
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-1715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:216 N LINCOLN WAY STE 40
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-1715
Practice Address - Country:US
Practice Address - Phone:209-744-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109773122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist