MEDICARE: DR. RAVEN ALEXANDER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	36836	TX

General Provider Information

NPI Number	:	1386133312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAVEN ALEXANDER DDS

Provider Business Mailing Address
First Line	:	2000 RICHEY ST
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77502-3332
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 RICHEY ST
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77502-3332
Country	:	US
Telephone Number	:	901-486-4101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2018
Last Update Date	:	01/10/2021

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