Provider Demographics
NPI:1952893216
Name:MAHMOUDI, ANISSA (DDS)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:
Last Name:MAHMOUDI
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 1:1537 S SCATTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-5766
Mailing Address - Country:US
Mailing Address - Phone:765-649-4995
Mailing Address - Fax:
Practice Address - Street 1:1537 S SCATTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-5766
Practice Address - Country:US
Practice Address - Phone:765-649-4995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-03
Last Update Date:2018-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012930A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist