Provider Demographics
NPI:1962992834
Name:ELLINGSEN ROEHRIG, ALEXA BRADY (DDS)
Entity type:Individual
Prefix:DR
First Name:ALEXA
Middle Name:BRADY
Last Name:ELLINGSEN ROEHRIG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ALEXA
Other - Middle Name:BRADY
Other - Last Name:ELLINGSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1509 W PINEHILL RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-2946
Mailing Address - Country:US
Mailing Address - Phone:509-389-6769
Mailing Address - Fax:
Practice Address - Street 1:3425 ERIE BLVD E
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:NY
Practice Address - Zip Code:13214-1635
Practice Address - Country:US
Practice Address - Phone:315-445-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY060673-011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program