Provider Demographics
NPI:1982770988
Name:JEFFREY P ALEXANDER DDS A DENTAL CORP
Entity Type:Organization
Organization Name:JEFFREY P ALEXANDER DDS A DENTAL CORP
Other - Org Name:YOUTHFUL TOOTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-568-3577
Mailing Address - Street 1:2762 PINOLE VALLEY RD.
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564
Mailing Address - Country:US
Mailing Address - Phone:510-758-6684
Mailing Address - Fax:510-669-2083
Practice Address - Street 1:2762 PINOLE VALLEY RD.
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564
Practice Address - Country:US
Practice Address - Phone:510-758-6684
Practice Address - Fax:510-669-2083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA263271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93765Medicaid