Provider Demographics
NPI:1245907070
Name:KOLEILAT, ANASS (DDS,MS)
Entity type:Individual
Prefix:DR
First Name:ANASS
Middle Name:
Last Name:KOLEILAT
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MEYER RD APT 622
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1015
Mailing Address - Country:US
Mailing Address - Phone:716-544-6161
Mailing Address - Fax:
Practice Address - Street 1:32316 5 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-6109
Practice Address - Country:US
Practice Address - Phone:734-523-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-28
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601126122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist