Provider Demographics
NPI:1740873512
Name:BORGESTAD, ALEXIS LAIN
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:LAIN
Last Name:BORGESTAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 WACHESAW RD
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-5633
Mailing Address - Country:US
Mailing Address - Phone:843-357-9845
Mailing Address - Fax:843-357-9847
Practice Address - Street 1:645 WACHESAW RD
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5633
Practice Address - Country:US
Practice Address - Phone:843-357-9845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.105781223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics