Provider Demographics
NPI:1043466071
Name:ALEXANDER, KELLY (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:ALEXANDER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 860036
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0036
Mailing Address - Country:US
Mailing Address - Phone:330-968-2268
Mailing Address - Fax:
Practice Address - Street 1:2931 STATE ROAD
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223
Practice Address - Country:US
Practice Address - Phone:330-968-2268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH22154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2649334Medicaid