Healthcare Provider Details

I. General information

NPI: 1194243121
Provider Name (Legal Business Name): ALYSON DREW DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 BUSINESS CENTER DR
SAN BERNARDINO CA
92408-3460
US

IV. Provider business mailing address

25926 VAN LEUVEN ST
LOMA LINDA CA
92354-6505
US

V. Phone/Fax

Practice location:
  • Phone: 269-830-0077
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number107874
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: