Provider Demographics
NPI:1831297431
Name:KLASSEN, ALEXIS CECELLA MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:CECELLA MARIE
Last Name:KLASSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ALEXIS
Other - Middle Name:CECELIA MARIE
Other - Last Name:KLASSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:510 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43469-1014
Mailing Address - Country:US
Mailing Address - Phone:810-623-2560
Mailing Address - Fax:
Practice Address - Street 1:1717 CROGHAN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-2758
Practice Address - Country:US
Practice Address - Phone:810-623-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019361122300000X
OH30-023383122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1194784934Medicare UPIN