Provider Demographics
NPI:1336215888
Name:CONCEPCION, ANNA MELISSA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANNA MELISSA
Middle Name:
Last Name:CONCEPCION
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 E 65TH ST
Mailing Address - Street 2:APT. 2A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6887
Mailing Address - Country:US
Mailing Address - Phone:617-970-0476
Mailing Address - Fax:
Practice Address - Street 1:30 CENTRAL PARK S
Practice Address - Street 2:SUITE 11D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1628
Practice Address - Country:US
Practice Address - Phone:212-838-0673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053151-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02817421Medicaid