Healthcare Provider Details

I. General information

NPI: 1194362848
Provider Name (Legal Business Name): AVERY CHIKEZIE ANAJE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3060 MOBILE HIGHWAY
MONTGOMERY AL
36108
US

IV. Provider business mailing address

3505 NW 89TH TERRACE
COOPER CITY FL
33024
US

V. Phone/Fax

Practice location:
  • Phone: 334-293-6670
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberD.0006720-C1
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: