Provider Demographics
NPI:1578576435
Name:MAZRATIAN, ALEXANDER (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:
Last Name:MAZRATIAN
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 1:1110 LONGFELLOW DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-4820
Mailing Address - Country:US
Mailing Address - Phone:409-898-2068
Mailing Address - Fax:
Practice Address - Street 1:1110 LONGFELLOW DR
Practice Address - Street 2:SUITE B
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-4820
Practice Address - Country:US
Practice Address - Phone:409-898-2068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171511223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX007762001Medicaid