Provider Demographics
NPI:1508850272
Name:SPINA, ANTHONY M (DDS MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:M
Last Name:SPINA
Suffix:
Gender:M
Credentials:DDS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4267
Mailing Address - Country:US
Mailing Address - Phone:847-268-3910
Mailing Address - Fax:847-897-3118
Practice Address - Street 1:22 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4267
Practice Address - Country:US
Practice Address - Phone:847-268-3910
Practice Address - Fax:847-897-3118
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190222511223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019022251Medicaid
IL019022251Medicaid
ILL71127Medicare ID - Type Unspecified
ILL98845Medicare ID - Type Unspecified
ILL97493Medicare ID - Type Unspecified
G37962Medicare UPIN