Healthcare Provider Details

I. General information

NPI: 1255997532
Provider Name (Legal Business Name): ALEJANDRO CISNEROS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 OPPORTUNITY BLVD S
CAMBRIDGE MN
55008-1238
US

IV. Provider business mailing address

4515 121ST AVE NE
BLAINE MN
55449-7065
US

V. Phone/Fax

Practice location:
  • Phone: 763-689-1554
  • Fax:
Mailing address:
  • Phone: 714-600-4660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD14169
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: