Healthcare Provider Details

I. General information

NPI: 1740873512
Provider Name (Legal Business Name): ALEXIS LAIN BORGESTAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 WACHESAW RD
MURRELLS INLET SC
29576-5633
US

IV. Provider business mailing address

645 WACHESAW RD
MURRELLS INLET SC
29576-5633
US

V. Phone/Fax

Practice location:
  • Phone: 843-357-9845
  • Fax:
Mailing address:
  • Phone: 843-357-9845
  • Fax: 843-357-9847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDGD.10578
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: