Provider Demographics
NPI:1740804244
Name:ANAST, ANISSA CELENA (DMD)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:CELENA
Last Name:ANAST
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21W152 BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5210
Mailing Address - Country:US
Mailing Address - Phone:708-214-2572
Mailing Address - Fax:
Practice Address - Street 1:920 N ELMHURST RD
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-1126
Practice Address - Country:US
Practice Address - Phone:224-347-3475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0325781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice