Provider Demographics
NPI:1013532100
Name:KOMOGORTSEVA, ALEKSANDRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALEKSANDRA
Middle Name:
Last Name:KOMOGORTSEVA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 OCEAN AVE APT 4M
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-4926
Mailing Address - Country:US
Mailing Address - Phone:347-339-1848
Mailing Address - Fax:
Practice Address - Street 1:1407 N VETERANS PKWY STE 12
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6425
Practice Address - Country:US
Practice Address - Phone:309-233-3922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2022-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014181741223G0001X
IL0190339851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice