Provider Demographics
NPI:1194227090
Name:ALEXANDRA DENTAL LLC
Entity type:Organization
Organization Name:ALEXANDRA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNIE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-467-0387
Mailing Address - Street 1:654 VALLEY CUB DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:AL
Mailing Address - Zip Code:36250-4200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:654 VALLEY CUB DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:AL
Practice Address - Zip Code:36250-4200
Practice Address - Country:US
Practice Address - Phone:256-847-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL171653Medicaid