Provider Demographics
NPI:1255084166
Name:WEISS, ALEXA NICOLE (LDH)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:NICOLE
Last Name:WEISS
Suffix:
Gender:F
Credentials:LDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 N JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:56087-4502
Mailing Address - Country:US
Mailing Address - Phone:507-723-4375
Mailing Address - Fax:
Practice Address - Street 1:602 N JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MN
Practice Address - Zip Code:56087-4502
Practice Address - Country:US
Practice Address - Phone:507-723-4375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH11217124Q00000X
MNDT145125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
No124Q00000XDental ProvidersDental Hygienist