Healthcare Provider Details

I. General information

NPI: 1497285779
Provider Name (Legal Business Name): ALEX HRADEK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 3RD ST
FORT POLK LA
71459-5102
US

IV. Provider business mailing address

1585 3RD ST
FORT POLK LA
71459-5102
US

V. Phone/Fax

Practice location:
  • Phone: 337-531-4854
  • Fax:
Mailing address:
  • Phone: 337-531-4854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.025039
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: