Provider Demographics
NPI:1700031127
Name:ANAST, PAUL THEODORE (DMD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:THEODORE
Last Name:ANAST
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 N FRANKLIN ST
Mailing Address - Street 2:#1104
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-8793
Mailing Address - Country:US
Mailing Address - Phone:618-530-5816
Mailing Address - Fax:
Practice Address - Street 1:1121 E SIBLEY BLVD
Practice Address - Street 2:
Practice Address - City:DOLTON
Practice Address - State:IL
Practice Address - Zip Code:60419-2827
Practice Address - Country:US
Practice Address - Phone:708-201-1072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027804122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist