Provider Demographics
NPI:1184302697
Name:SALAKHUTDINOV, ANVAR (DMD)
Entity type:Individual
Prefix:
First Name:ANVAR
Middle Name:
Last Name:SALAKHUTDINOV
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 1:1619 GRANT AVE STE 23
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3161
Mailing Address - Country:US
Mailing Address - Phone:215-673-4940
Mailing Address - Fax:215-673-4960
Practice Address - Street 1:1619 GRANT AVE STE 23
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3161
Practice Address - Country:US
Practice Address - Phone:215-673-4940
Practice Address - Fax:215-673-4960
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS044217122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist