Provider Demographics
NPI:1104487222
Name:STANCO, ALEX
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:STANCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 ROLLING HILLS DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-7838
Mailing Address - Country:US
Mailing Address - Phone:203-362-9459
Mailing Address - Fax:
Practice Address - Street 1:500 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2169
Practice Address - Country:US
Practice Address - Phone:928-289-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12860122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist