Provider Demographics
NPI:1699753988
Name:ALEXANDER, JACK (DMD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:ALEXANDER
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 1:9434 HOSPITAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:NASSAWADOX
Mailing Address - State:VA
Mailing Address - Zip Code:23413
Mailing Address - Country:US
Mailing Address - Phone:757-414-0400
Mailing Address - Fax:757-414-0569
Practice Address - Street 1:9434 HOSPITAL AVENUE
Practice Address - Street 2:
Practice Address - City:NASSAWADOX
Practice Address - State:VA
Practice Address - Zip Code:23413
Practice Address - Country:US
Practice Address - Phone:757-414-0400
Practice Address - Fax:757-414-0569
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008253122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V04287Medicare UPIN