Provider Demographics
NPI:1265415244
Name:SONI, ANSHUMAN (DDS)
Entity type:Individual
Prefix:DR
First Name:ANSHUMAN
Middle Name:
Last Name:SONI
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 1:1418 S MILWAUKEE AVE
Mailing Address - Street 2:SUITE # 4
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048
Mailing Address - Country:US
Mailing Address - Phone:847-984-2548
Mailing Address - Fax:847-984-2957
Practice Address - Street 1:1418 S MILWAUKEE AVE
Practice Address - Street 2:SUITE # 4
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048
Practice Address - Country:US
Practice Address - Phone:847-984-2548
Practice Address - Fax:847-984-2957
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190262891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019026289OtherLICENSE
IL9176879OtherDOREL