Provider Demographics
NPI:1083723118
Name:VANACKER, ALEX R (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:R
Last Name:VANACKER
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:PO BOX 318
Mailing Address - Street 2:712 S BROADWAY
Mailing Address - City:PENROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81240-0318
Mailing Address - Country:US
Mailing Address - Phone:719-372-3041
Mailing Address - Fax:719-372-0163
Practice Address - Street 1:712 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PENROSE
Practice Address - State:CO
Practice Address - Zip Code:81240-9003
Practice Address - Country:US
Practice Address - Phone:719-372-3041
Practice Address - Fax:719-372-0163
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCOLO105937122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
89152OtherUNITED CONCORDIA
CO02105930Medicaid