=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356514772
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEXANDER DENTAL GROUOP CHTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2008
-----------------------------------------------------
Last Update Date | 04/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 506 HANSEN ST E
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-6254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-733-7566
-----------------------------------------------------
Fax | 208-734-4267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 506 HANSEN ST E
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-6254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-733-7566
-----------------------------------------------------
Fax | 208-734-4267
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JEANETTE SHARP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-733-7566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------