Provider Demographics
NPI:1912045147
Name:AHMADI, ANISSA (DMD)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:
Last Name:AHMADI
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 1:45 BARKLEY CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7531
Mailing Address - Country:US
Mailing Address - Phone:239-939-0423
Mailing Address - Fax:239-939-4912
Practice Address - Street 1:45 BARKLEY CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7531
Practice Address - Country:US
Practice Address - Phone:239-939-0423
Practice Address - Fax:239-939-4912
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN162621223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry