Healthcare Provider Details

I. General information

NPI: 1053650655
Provider Name (Legal Business Name): ALEXANDRA M URENA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2013
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8153 SHELDON RD APT 102
ELK GROVE CA
95758-1284
US

IV. Provider business mailing address

47 5TH ST NW
WINTER HAVEN FL
33881-4672
US

V. Phone/Fax

Practice location:
  • Phone: 305-270-1550
  • Fax:
Mailing address:
  • Phone: 863-268-7850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number54613
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH11724
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: