Provider Demographics
NPI:1831238096
Name:ANISIMOVA, ANGELINA (DDS)
Entity type:Individual
Prefix:DR
First Name:ANGELINA
Middle Name:
Last Name:ANISIMOVA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:589 MID RIVERS MALL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2152
Mailing Address - Country:US
Mailing Address - Phone:636-970-1595
Mailing Address - Fax:636-279-1117
Practice Address - Street 1:589 MID RIVERS MALL DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2152
Practice Address - Country:US
Practice Address - Phone:636-970-1595
Practice Address - Fax:636-279-1117
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003013493122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO408833614Medicaid