Healthcare Provider Details

I. General information

NPI: 1588829980
Provider Name (Legal Business Name): ANITA MARIE MASAITIS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 07/15/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 1ST ST WANBLEE HEALTH CENTER
WANBLEE SD
57577
US

IV. Provider business mailing address

PO BOX 40760
MESA AZ
85274
US

V. Phone/Fax

Practice location:
  • Phone: 605-462-5630
  • Fax: 605-462-6631
Mailing address:
  • Phone: 480-706-9430
  • Fax: 480-461-1785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number016.0101177
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2302
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: