Healthcare Provider Details

I. General information

NPI: 1205190022
Provider Name (Legal Business Name): ALEXANDRA V BRENNAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

392 SALEM TPK
BOZRAH CT
06334
US

IV. Provider business mailing address

392 SALEM TPK
BOZRAH CT
06334
US

V. Phone/Fax

Practice location:
  • Phone: 860-886-5576
  • Fax: 860-885-1379
Mailing address:
  • Phone: 860-886-5576
  • Fax: 860-885-1379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number11364
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberLD00076
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: