Provider Demographics
NPI:1174029649
Name:PIEDRA, ALEX (DDS)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:PIEDRA
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 1:1367 S AMBASSADOR WAY
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2860
Mailing Address - Country:US
Mailing Address - Phone:206-535-4416
Mailing Address - Fax:206-535-4416
Practice Address - Street 1:2205 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2437
Practice Address - Country:US
Practice Address - Phone:509-574-3220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX359481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program