Healthcare Provider Details

I. General information

NPI: 1144209073
Provider Name (Legal Business Name): ALEXANDER KARL DEITCH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE ROAD PRDC, USA DENTAC HAWAII CREDENTIALS OFFICE
HONOLULU HI
96859-5000
US

IV. Provider business mailing address

1 JARRETT WHITE ROAD PRDC, USA DENTAC HAWAII CREDENTIALS OFFICE
HONOLULU HI
96859-5000
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-1021
  • Fax:
Mailing address:
  • Phone: 808-433-1021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDE00009035
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number40927
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: