Provider Demographics
NPI:1609249846
Name:DYSART, ANN
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:DYSART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 SYCAMORE AVE
Mailing Address - Street 2:APT 1617
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6710
Mailing Address - Country:US
Mailing Address - Phone:609-306-0198
Mailing Address - Fax:
Practice Address - Street 1:45 SYCAMORE AVE
Practice Address - Street 2:APT 1617
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-6710
Practice Address - Country:US
Practice Address - Phone:609-306-0198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8616122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist