Provider Demographics
NPI:1831414119
Name:ALEX GLADKOV A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:ALEX GLADKOV A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:GLADKOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-953-6881
Mailing Address - Street 1:1920 E 17TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-8626
Mailing Address - Country:US
Mailing Address - Phone:714-953-6881
Mailing Address - Fax:714-558-8618
Practice Address - Street 1:1920 E 17TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8626
Practice Address - Country:US
Practice Address - Phone:714-953-6881
Practice Address - Fax:714-558-8618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA408221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty