Provider Demographics
NPI:1063821346
Name:ALEXANDER HAZBOUN, GILLIAN (DDS, MS, FACP)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:ALEXANDER HAZBOUN
Suffix:
Gender:F
Credentials:DDS, MS, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 819 BOX 18
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09645-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 819 BOX 18
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09645-0001
Practice Address - Country:US
Practice Address - Phone:314-727-3733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0571731223G0001X, 1223P0700X
PADS0394621223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice