Provider Demographics
NPI:1952714149
Name:OMER M ANISSO DDS INC
Entity Type:Organization
Organization Name:OMER M ANISSO DDS INC
Other - Org Name:LA COSTA DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMER
Authorized Official - Middle Name:
Authorized Official - Last Name:ANISSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-436-2452
Mailing Address - Street 1:501 N EL CAMINO REAL STE 200
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 N EL CAMINO REAL STE 200
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1335
Practice Address - Country:US
Practice Address - Phone:760-436-2452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54467122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty