1205190022 NPI number — DR. ALEXANDRA V BRENNAN DMD

Table of content: DR. ALEXANDRA V BRENNAN DMD (NPI 1205190022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205190022 NPI number — DR. ALEXANDRA V BRENNAN DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENNAN
Provider First Name:
ALEXANDRA
Provider Middle Name:
V
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205190022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
392 SALEM TPK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOZRAH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-886-5576
Provider Business Mailing Address Fax Number:
860-885-1379

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
392 SALEM TPK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOZRAH
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-886-5576
Provider Business Practice Location Address Fax Number:
860-885-1379
Provider Enumeration Date:
06/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  11364 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: LD00076 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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