Provider Demographics
NPI:1285120824
Name:POWERS, ALYSSHA BONIQUE (DMD)
Entity type:Individual
Prefix:DR
First Name:ALYSSHA
Middle Name:BONIQUE
Last Name:POWERS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15036 NORMANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32234-2302
Mailing Address - Country:US
Mailing Address - Phone:904-891-7080
Mailing Address - Fax:
Practice Address - Street 1:1747 US HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4238
Practice Address - Country:US
Practice Address - Phone:904-717-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN23553122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist