Provider Demographics
NPI:1144619982
Name:MORENO, ALEXANDER JAKE ALFONSO (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER JAKE
Middle Name:ALFONSO
Last Name:MORENO
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 1:178 S VICTORIA AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-4329
Mailing Address - Country:US
Mailing Address - Phone:805-658-0700
Mailing Address - Fax:805-658-0777
Practice Address - Street 1:178 S VICTORIA AVE
Practice Address - Street 2:SUITE C
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-4329
Practice Address - Country:US
Practice Address - Phone:805-658-0700
Practice Address - Fax:805-658-0777
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA640651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice