Healthcare Provider Details

I. General information

NPI: 1083885685
Provider Name (Legal Business Name): KEITH ALAN ALEXANDER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2008
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 LYNDON RD
FAYETTEVILLE NY
13066-1016
US

IV. Provider business mailing address

30 LYNDON RD
FAYETTEVILLE NY
13066-1016
US

V. Phone/Fax

Practice location:
  • Phone: 315-460-0110
  • Fax:
Mailing address:
  • Phone: 315-460-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number56884
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number055459
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: