Healthcare Provider Details

I. General information

NPI: 1912151838
Provider Name (Legal Business Name): KEISHA N ALEXANDER D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1074 SPRING LAKE SQ
WINTER HAVEN FL
33881
US

IV. Provider business mailing address

1074 SPRING LAKE SQ
WINTER HAVEN FL
33881
US

V. Phone/Fax

Practice location:
  • Phone: 863-291-4500
  • Fax: 863-299-3781
Mailing address:
  • Phone: 863-291-4500
  • Fax: 863-299-3781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN 18362
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8460
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: