Provider Demographics
NPI:1386429728
Name:ALAM, ANISA MARYAM (DMD)
Entity type:Individual
Prefix:DR
First Name:ANISA
Middle Name:MARYAM
Last Name:ALAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 BLACKMON DR STE 310
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2570 BLACKMON DR STE 310
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6197
Practice Address - Country:US
Practice Address - Phone:678-203-3462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1232301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice