Provider Demographics
NPI:1952753964
Name:CONGIUSTA, ANTHONY D (MD, DDS)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:D
Last Name:CONGIUSTA
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-1720
Mailing Address - Country:US
Mailing Address - Phone:917-359-6088
Mailing Address - Fax:
Practice Address - Street 1:4774 MUNSON ST NW STE 102
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3634
Practice Address - Country:US
Practice Address - Phone:330-494-6653
Practice Address - Fax:330-494-6630
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040943122300000X
OK75561223S0112X
OH30.0271031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist