Provider Demographics
NPI:1609889187
Name:COLETTA, ANTHONY JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JOSEPH
Last Name:COLETTA
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 1:1064 WHITEWATER LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-0377
Mailing Address - Country:US
Mailing Address - Phone:630-428-3778
Mailing Address - Fax:
Practice Address - Street 1:11711 W BURLEIGH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-3108
Practice Address - Country:US
Practice Address - Phone:414-771-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5970-0151223G0001X
IL01999211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33798600Medicaid