Provider Demographics
NPI:1013018274
Name:IVANOFF, ALEXANDER EUGENE (DDS)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:EUGENE
Last Name:IVANOFF
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 LOVALL VALLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-3629
Mailing Address - Country:US
Mailing Address - Phone:707-938-1510
Mailing Address - Fax:707-935-1425
Practice Address - Street 1:17776 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-3629
Practice Address - Country:US
Practice Address - Phone:707-935-8200
Practice Address - Fax:707-935-8272
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26653122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist