Healthcare Provider Details

I. General information

NPI: 1811445042
Provider Name (Legal Business Name): ANIKA ISLAM DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2016
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USNMRTU IWAKUNI, BLDG 110, MCAS IWAKUNI, 1 MISUMI MACHI
IWAKUNI YAMAGUCHI
7400025
JP

IV. Provider business mailing address

PSC 561 BOX 1877
FPO AP
96310-0019
US

V. Phone/Fax

Practice location:
  • Phone: 315-255-8520
  • Fax:
Mailing address:
  • Phone: 315-255-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN015166
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: