Provider Demographics
NPI:1891205084
Name:RISTAU, ALEXANDER (DMD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:RISTAU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 HIGHWAY 70 E STE 2
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-7013
Mailing Address - Country:US
Mailing Address - Phone:615-446-4644
Mailing Address - Fax:
Practice Address - Street 1:102 HIGHWAY 70 E STE 2
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-7013
Practice Address - Country:US
Practice Address - Phone:615-446-4644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-27121223G0001X
TN106721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice