=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114533064
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEXANDER V. ANTIPOV, D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2020
-----------------------------------------------------
Last Update Date | 09/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 911 RESERVE DRIVE, SUITE 150
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-783-2110
-----------------------------------------------------
Fax | 916-783-2111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 911 RESERVE DRIVE, SUITE 150
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-783-2110
-----------------------------------------------------
Fax | 916-783-2111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALEXANDER ANTIPOV
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 916-783-2110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------