Provider Demographics
NPI:1245908474
Name:DEZA, ANTHONY E (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:E
Last Name:DEZA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18306 BERRY RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-8869
Mailing Address - Country:US
Mailing Address - Phone:951-452-0089
Mailing Address - Fax:
Practice Address - Street 1:23080 ALESSANDRO BLVD STE 201
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-9674
Practice Address - Country:US
Practice Address - Phone:951-697-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106894122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106894Medicaid