Provider Demographics
NPI:1558376046
Name:ANISSO, OMER (DDS)
Entity Type:Individual
Prefix:DR
First Name:OMER
Middle Name:
Last Name:ANISSO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N EL CAMINO REAL
Mailing Address - Street 2:SUITE# 2
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1335
Mailing Address - Country:US
Mailing Address - Phone:760-436-2452
Mailing Address - Fax:
Practice Address - Street 1:501 N EL CAMINO REAL
Practice Address - Street 2:SUITE# 2
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1335
Practice Address - Country:US
Practice Address - Phone:760-436-2452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA544671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice