Provider Demographics
NPI:1174272694
Name:DANTZLER, ALEXA VICTORIA (MD)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:VICTORIA
Last Name:DANTZLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12153 PEARL BAY RDG
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-8980
Mailing Address - Country:US
Mailing Address - Phone:703-309-3557
Mailing Address - Fax:
Practice Address - Street 1:3225 SHALLOWFORD RD STE 1300
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-7033
Practice Address - Country:US
Practice Address - Phone:703-309-3557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103932208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty