Provider Demographics
NPI:1326601352
Name:BROESDER, ALEX WILSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:WILSON
Last Name:BROESDER
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 1:2400 W 41ST ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-6119
Mailing Address - Country:US
Mailing Address - Phone:605-929-1980
Mailing Address - Fax:
Practice Address - Street 1:2400 W 41ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105
Practice Address - Country:US
Practice Address - Phone:605-929-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD1234122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist