Provider Demographics
NPI:1609809292
Name:IMMEDIATA, ANTHONY RUSSELL (DMD, PA)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:RUSSELL
Last Name:IMMEDIATA
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 CREEDMOOR RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-1682
Mailing Address - Country:US
Mailing Address - Phone:919-846-5500
Mailing Address - Fax:
Practice Address - Street 1:7101 CREEDMOOR RD
Practice Address - Street 2:SUITE 109
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-1682
Practice Address - Country:US
Practice Address - Phone:919-846-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC50221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8994426Medicaid
NC2340076Medicare ID - Type Unspecified
NCU08372Medicare UPIN