Healthcare Provider Details

I. General information

NPI: 1952714149
Provider Name (Legal Business Name): OMER M ANISSO DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N EL CAMINO REAL STE 200
ENCINITAS CA
92024-1335
US

IV. Provider business mailing address

501 N EL CAMINO REAL STE 200
ENCINITAS CA
92024-1335
US

V. Phone/Fax

Practice location:
  • Phone: 760-436-2452
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number54467
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: OMER ANISSO
Title or Position: OWNER
Credential: DDS
Phone: 760-436-2452