Healthcare Provider Details

I. General information

NPI: 1962248658
Provider Name (Legal Business Name): ALEXIS BIANCA ALICEA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 HIGHWAY 138 SE
CONYERS GA
30013-1285
US

IV. Provider business mailing address

2291 WILKINS CT
DECATUR GA
30035-3620
US

V. Phone/Fax

Practice location:
  • Phone: 770-285-2270
  • Fax:
Mailing address:
  • Phone: 407-755-9398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN124377
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: