Provider Demographics
NPI:1063591931
Name:BRODSKY, ALEXANDER GREGORY (DMD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:GREGORY
Last Name:BRODSKY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10618 SW 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-6992
Mailing Address - Country:US
Mailing Address - Phone:503-488-5984
Mailing Address - Fax:
Practice Address - Street 1:3653 SE 34TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3034
Practice Address - Country:US
Practice Address - Phone:503-988-4410
Practice Address - Fax:503-988-5642
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD74651223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health