Provider Demographics
NPI:1033327812
Name:MAGALLANES, ALEXANDER JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:JOSEPH
Last Name:MAGALLANES
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 1:619 PALO ALTO DR
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-7320
Mailing Address - Country:US
Mailing Address - Phone:909-380-5443
Mailing Address - Fax:951-940-5853
Practice Address - Street 1:330 E 4TH ST
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570
Practice Address - Country:US
Practice Address - Phone:909-380-5443
Practice Address - Fax:951-940-5853
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA416431223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91281-01Medicaid
CAG91281-02Medicaid