Provider Demographics
NPI:1386708055
Name:AMINOSHARIAE, ANITA (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:ANITA
Middle Name:
Last Name:AMINOSHARIAE
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
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Mailing Address - Street 1:PO BOX 860036
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486
Mailing Address - Country:US
Mailing Address - Phone:651-343-9277
Mailing Address - Fax:651-343-9277
Practice Address - Street 1:25 LAKE ST N
Practice Address - Street 2:STE 110
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2535
Practice Address - Country:US
Practice Address - Phone:651-464-7388
Practice Address - Fax:651-982-6236
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND119421223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN208304300Medicaid