Provider Demographics
NPI:1063978112
Name:SISHTA, ANIL
Entity type:Individual
Prefix:DR
First Name:ANIL
Middle Name:
Last Name:SISHTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 3RD AVE APT 908
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4349
Mailing Address - Country:US
Mailing Address - Phone:908-328-5263
Mailing Address - Fax:
Practice Address - Street 1:21 DIVISION AVE
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-2919
Practice Address - Country:US
Practice Address - Phone:516-274-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061208122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist