Healthcare Provider Details

I. General information

NPI: 1588635072
Provider Name (Legal Business Name): DR. ALEXANDER ROYZENBLAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 10/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 ADMIRAL TAUSSIG BLVD SEWELL'S POINT BRANCH MEDICAL CLINIC
NORFOLK VA
23511-2802
US

IV. Provider business mailing address

903 HENPHIL FARMS CT
CHESAPEAKE VA
23320-8199
US

V. Phone/Fax

Practice location:
  • Phone: 760-613-3917
  • Fax:
Mailing address:
  • Phone: 760-613-3917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4278
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901018211
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6495-15
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019028225
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number49796
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401414365
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: