Healthcare Provider Details

I. General information

NPI: 1982455804
Provider Name (Legal Business Name): ALEXANDRIA IZORA JONES DENTAL THERAPY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 MILUK DR
COOS BAY OR
97420-7728
US

IV. Provider business mailing address

109 ELM ST
PHOENIX OR
97535-7765
US

V. Phone/Fax

Practice location:
  • Phone: 541-888-9494
  • Fax:
Mailing address:
  • Phone: 541-816-8266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT0020
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: