Provider Demographics
NPI:1245793405
Name:MCDONALD, ANNA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22810 SUNSET CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1029
Mailing Address - Country:US
Mailing Address - Phone:317-805-9137
Mailing Address - Fax:
Practice Address - Street 1:22810 SUNSET CROSSING RD
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1029
Practice Address - Country:US
Practice Address - Phone:317-805-9137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97124Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice