Provider Demographics
NPI:1538945803
Name:ANTONY, NEETHA ANIYA (BDS)
Entity type:Individual
Prefix:
First Name:NEETHA
Middle Name:ANIYA
Last Name:ANTONY
Suffix:
Gender:F
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WINCHESTER DR UNIT 202
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-5243
Mailing Address - Country:US
Mailing Address - Phone:669-225-8208
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2617
Practice Address - Country:US
Practice Address - Phone:207-221-4714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-04
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN50721223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X2210XDental ProvidersDentistOrofacial Pain
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEDEN5072OtherDENTAL LICENSE