Provider Demographics
NPI:1720843071
Name:ESTANISLAU, ALEXANDRA MARIA
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:MARIA
Last Name:ESTANISLAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 WINDING BROOK LN
Mailing Address - Street 2:
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-1478
Mailing Address - Country:US
Mailing Address - Phone:413-374-4154
Mailing Address - Fax:
Practice Address - Street 1:4915 25TH AVE NE STE 205
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5668
Practice Address - Country:US
Practice Address - Phone:206-524-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA01223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice