Provider Demographics
NPI:1831762061
Name:BULLOCK, ALEX THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:ALEX
Middle Name:THOMAS
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USA DENTAC HEALTH ACTIVITY
Mailing Address - Street 2:36000 SHOEMAKER LANE, SUITE 1051
Mailing Address - City:FORT CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5054
Mailing Address - Country:US
Mailing Address - Phone:254-287-2705
Mailing Address - Fax:
Practice Address - Street 1:36000 SHOEMAKER LANE, STE 1051
Practice Address - Street 2:
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-287-2705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-24
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011161122300000X
CA106428122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist