Provider Demographics
NPI:1679145940
Name:VIDAL, ALEXIS VALENTINA
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:VALENTINA
Last Name:VIDAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:VALENTINA
Other - Last Name:SUNSTEIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2441 21ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5582
Mailing Address - Country:US
Mailing Address - Phone:207-798-5429
Mailing Address - Fax:
Practice Address - Street 1:2441 21ST ST
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5582
Practice Address - Country:US
Practice Address - Phone:207-798-5429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant