Provider Demographics
NPI:1992059364
Name:JETT, ALEXANDRA MARIA (RDH)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:MARIA
Last Name:JETT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SW STARK ST
Mailing Address - Street 2:9TH FLOOR DENTAL
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-2302
Mailing Address - Country:US
Mailing Address - Phone:503-988-5770
Mailing Address - Fax:
Practice Address - Street 1:33 NW BROADWAY
Practice Address - Street 2:SUITE 380
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3580
Practice Address - Country:US
Practice Address - Phone:503-988-5770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH4182124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist