Healthcare Provider Details

I. General information

NPI: 1952979452
Provider Name (Legal Business Name): ALEXANDER FUNK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2021
Last Update Date: 06/12/2021
Certification Date: 06/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 E KNOXVILLE ST
BRIMFIELD IL
61517-8178
US

IV. Provider business mailing address

232 E KNOXVILLE ST
BRIMFIELD IL
61517-8178
US

V. Phone/Fax

Practice location:
  • Phone: 309-396-3123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019033179
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: