Provider Demographics
NPI:1235665738
Name:BOUNEFF, ALEXANDER (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:
Last Name:BOUNEFF
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 NW 11TH AVE UNIT 1001
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2972
Mailing Address - Country:US
Mailing Address - Phone:971-241-2417
Mailing Address - Fax:
Practice Address - Street 1:3925 SW 153RD DR STE 100
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97003-4168
Practice Address - Country:US
Practice Address - Phone:503-646-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORD115861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program