Provider Demographics
NPI:1205190022
Name:BRENNAN, ALEXANDRA V (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:V
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 SALEM TPK
Mailing Address - Street 2:
Mailing Address - City:BOZRAH
Mailing Address - State:CT
Mailing Address - Zip Code:06334
Mailing Address - Country:US
Mailing Address - Phone:860-886-5576
Mailing Address - Fax:860-885-1379
Practice Address - Street 1:392 SALEM TPK
Practice Address - Street 2:
Practice Address - City:BOZRAH
Practice Address - State:CT
Practice Address - Zip Code:06334
Practice Address - Country:US
Practice Address - Phone:860-886-5576
Practice Address - Fax:860-885-1379
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT113641223P0221X
RILD00076122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist