Provider Demographics
NPI:1669209821
Name:FELICIANO, ALEJANDRO
Entity type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:
Last Name:FELICIANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:CORNELIA
Mailing Address - State:GA
Mailing Address - Zip Code:30531-5768
Mailing Address - Country:US
Mailing Address - Phone:706-778-7147
Mailing Address - Fax:
Practice Address - Street 1:592 MEDICAL PARK DR STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2055
Practice Address - Country:US
Practice Address - Phone:770-863-7324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1235976122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist