Provider Demographics
NPI:1740413012
Name:BELISLE, ANTHONY RAY JR (LD)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:RAY
Last Name:BELISLE
Suffix:JR
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3520
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0418
Mailing Address - Country:US
Mailing Address - Phone:541-267-7278
Mailing Address - Fax:541-269-4613
Practice Address - Street 1:965 S 1ST ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1401
Practice Address - Country:US
Practice Address - Phone:541-267-7278
Practice Address - Fax:541-269-4613
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-1003340122400000X
126900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
No126900000XDental ProvidersDental Laboratory Technician