Provider Demographics
NPI:1619025277
Name:VAISMAN, ANATOLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANATOLY
Middle Name:
Last Name:VAISMAN
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 1:11273 LAUREL CANYON BLVD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-4300
Mailing Address - Country:US
Mailing Address - Phone:818-365-7191
Mailing Address - Fax:818-361-7641
Practice Address - Street 1:11273 LAUREL CANYON BLVD
Practice Address - Street 2:SUITE #3
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4300
Practice Address - Country:US
Practice Address - Phone:818-365-7191
Practice Address - Fax:818-361-7641
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43259122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist