Provider Demographics
NPI:1033310115
Name:HAILEY, ANISA LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:ANISA
Middle Name:LEE
Last Name:HAILEY
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 1:4055 JOHNS CREEK PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1299
Mailing Address - Country:US
Mailing Address - Phone:678-436-1300
Mailing Address - Fax:678-436-1303
Practice Address - Street 1:4055 JOHNS CREEK PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1299
Practice Address - Country:US
Practice Address - Phone:678-436-1300
Practice Address - Fax:678-436-1303
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0120261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice