Healthcare Provider Details

I. General information

NPI: 1720378599
Provider Name (Legal Business Name): BANA A ANBARI DDS, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24803 DETROIT RD
WESTLAKE OH
44145-2553
US

IV. Provider business mailing address

31032 LOGAN CT
WESTLAKE OH
44145-6831
US

V. Phone/Fax

Practice location:
  • Phone: 440-835-5388
  • Fax:
Mailing address:
  • Phone: 440-808-8082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number30.022360
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: