Provider Demographics
NPI:1891894796
Name:AGNISH, POOJA ANJU (DMD)
Entity Type:Individual
Prefix:DR
First Name:POOJA
Middle Name:ANJU
Last Name:AGNISH
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 1:113 W INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN
Mailing Address - State:PA
Mailing Address - Zip Code:17872-5315
Mailing Address - Country:US
Mailing Address - Phone:570-644-3900
Mailing Address - Fax:570-644-3901
Practice Address - Street 1:113 W INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:SHAMOKIN
Practice Address - State:PA
Practice Address - Zip Code:17872-5315
Practice Address - Country:US
Practice Address - Phone:570-644-3900
Practice Address - Fax:570-644-3901
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS028254L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
680508925OtherEMPLOYER TAX ID#