Provider Demographics
NPI:1316284763
Name:ANJOMSHOAA, IDA
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:ANJOMSHOAA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 MOTT ST
Mailing Address - Street 2:APT #4C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012
Mailing Address - Country:US
Mailing Address - Phone:718-899-7811
Mailing Address - Fax:
Practice Address - Street 1:3353 82ND ST
Practice Address - Street 2:A01
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-1447
Practice Address - Country:US
Practice Address - Phone:718-899-7811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0580651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery